Healthcare Provider Details

I. General information

NPI: 1851720148
Provider Name (Legal Business Name): MARINA TEO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2013
Last Update Date: 02/25/2021
Certification Date: 02/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1907 BOYS REPUBLIC DR
CHINO HILLS CA
91709-5447
US

IV. Provider business mailing address

1907 BOYS REPUBLIC DR
CHINO HILLS CA
91709-5447
US

V. Phone/Fax

Practice location:
  • Phone: 909-628-1217
  • Fax: 909-306-5427
Mailing address:
  • Phone: 909-628-1217
  • Fax: 909-306-5427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMF88074
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number111257
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: