Healthcare Provider Details

I. General information

NPI: 1306969779
Provider Name (Legal Business Name): TERESA SUSAN ROLTGEN LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 09/02/2022
Certification Date: 09/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3114 WILLOW AVE
CLOVIS CA
93612-4750
US

IV. Provider business mailing address

PO BOX 25852
FRESNO CA
93729-5852
US

V. Phone/Fax

Practice location:
  • Phone: 559-286-6907
  • Fax:
Mailing address:
  • Phone: 559-262-2531
  • Fax: 559-434-7404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC33391
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: