Healthcare Provider Details

I. General information

NPI: 1104015882
Provider Name (Legal Business Name): TERI LYN GELGOOD MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2007
Last Update Date: 05/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

493 PLEASANT VALLEY RD SUITE 200
DIAMOND SPRINGS CA
95667-5321
US

IV. Provider business mailing address

2515 INDIAN WELLS RD
PLACERVILLE CA
95667-8103
US

V. Phone/Fax

Practice location:
  • Phone: 530-503-7040
  • Fax:
Mailing address:
  • Phone: 530-503-7040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT36536
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: