Provider Demographics
NPI:1881812840
Name:TETALMAN, AMY MARIE (MA, MFT)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:MARIE
Last Name:TETALMAN
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:MARIE
Other - Last Name:LENZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:444 ROSARIO DR
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93110-1121
Mailing Address - Country:US
Mailing Address - Phone:805-636-5366
Mailing Address - Fax:805-681-0029
Practice Address - Street 1:5901 ENCINA RD
Practice Address - Street 2:SUITE A
Practice Address - City:GOLETA
Practice Address - State:CA
Practice Address - Zip Code:93117-2269
Practice Address - Country:US
Practice Address - Phone:805-681-0035
Practice Address - Fax:805-681-0029
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 56685106H00000X
CA84544106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist