Provider Demographics
NPI:1457056137
Name:PALM, TEUILA (AMFT)
Entity Type:Individual
Prefix:
First Name:TEUILA
Middle Name:
Last Name:PALM
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6792 MERITO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-5745
Mailing Address - Country:US
Mailing Address - Phone:951-743-4966
Mailing Address - Fax:
Practice Address - Street 1:731 E 40TH ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-1448
Practice Address - Country:US
Practice Address - Phone:909-882-7978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA138197106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist