Provider Demographics
NPI:1689705436
Name:DAUSCH, THERESA MAUREEN
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:MAUREEN
Last Name:DAUSCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 E BROADWAY
Mailing Address - Street 2:#406
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-5113
Mailing Address - Country:US
Mailing Address - Phone:310-968-6126
Mailing Address - Fax:
Practice Address - Street 1:18302 IRVINE BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3435
Practice Address - Country:US
Practice Address - Phone:714-881-8671
Practice Address - Fax:714-957-1065
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF48060225400000X
CAMFC 49031101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner