Provider Demographics
NPI:1972665198
Name:LIVELY, TERESA JEAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:TERESA
Middle Name:JEAN
Last Name:LIVELY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5755 COTTLE RD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-3640
Mailing Address - Country:US
Mailing Address - Phone:408-363-4904
Mailing Address - Fax:408-972-3242
Practice Address - Street 1:5755 COTTLE RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95123-3640
Practice Address - Country:US
Practice Address - Phone:408-363-4904
Practice Address - Fax:408-972-3242
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20059103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist