Provider Demographics
NPI:1710010483
Name:KANAZAWA, TERU JUDY (LCSW)
Entity Type:Individual
Prefix:MS
First Name:TERU
Middle Name:JUDY
Last Name:KANAZAWA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:TERU
Other - Middle Name:KANAZAWA
Other - Last Name:SHEEHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1323 EAST WINDSOR RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-2662
Mailing Address - Country:US
Mailing Address - Phone:310-579-2047
Mailing Address - Fax:
Practice Address - Street 1:1323 EAST WINDSOR RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-2662
Practice Address - Country:US
Practice Address - Phone:310-579-2047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA276831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11298014100812-001OtherMEDICARE, ALLIED HEALTH
CAF0519AMedicare UPIN