Provider Demographics
NPI:1154387744
Name:CORTLAND, TERI (PSYD)
Entity type:Individual
Prefix:
First Name:TERI
Middle Name:
Last Name:CORTLAND
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77935 CALLE TAMPICO
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-2947
Mailing Address - Country:US
Mailing Address - Phone:760-564-5838
Mailing Address - Fax:760-771-4684
Practice Address - Street 1:77935 CALLE TAMPICO
Practice Address - Street 2:SUITE 204
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-2947
Practice Address - Country:US
Practice Address - Phone:760-564-5838
Practice Address - Fax:760-771-4684
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-24
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20395103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMMM00427MMedicare ID - Type Unspecified