Provider Demographics
NPI:1912307984
Name:TETELMAN, AZA (PSYD)
Entity Type:Individual
Prefix:
First Name:AZA
Middle Name:
Last Name:TETELMAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:AZALEA
Other - Middle Name:
Other - Last Name:TETELMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1470 CIVIC CT STE 110
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-5290
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1470 CIVIC CT STE 110
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-5290
Practice Address - Country:US
Practice Address - Phone:925-680-0222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-27
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program