Provider Demographics
NPI:1942435508
Name:DE COSSY, TEREN R (IMF)
Entity Type:Individual
Prefix:
First Name:TEREN
Middle Name:R
Last Name:DE COSSY
Suffix:
Gender:F
Credentials:IMF
Other - Prefix:
Other - First Name:THELMA
Other - Middle Name:
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:303 POTRERO ST
Mailing Address - Street 2:UNIT 05B
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-2741
Mailing Address - Country:US
Mailing Address - Phone:831-429-2270
Mailing Address - Fax:
Practice Address - Street 1:303 POTRERO ST
Practice Address - Street 2:UNIT 05B
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-2741
Practice Address - Country:US
Practice Address - Phone:831-429-2270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-26
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49730106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAIMF 53030OtherINTERN