Healthcare Provider Details

I. General information

NPI: 1154387744
Provider Name (Legal Business Name): TERI CORTLAND PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2006
Last Update Date: 05/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77935 CALLE TAMPICO SUITE 204
LA QUINTA CA
92253-2947
US

IV. Provider business mailing address

77935 CALLE TAMPICO SUITE 204
LA QUINTA CA
92253-2947
US

V. Phone/Fax

Practice location:
  • Phone: 760-564-5838
  • Fax: 760-771-4684
Mailing address:
  • Phone: 760-564-5838
  • Fax: 760-771-4684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY20395
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: