Healthcare Provider Details

I. General information

NPI: 1548042195
Provider Name (Legal Business Name): TEO LIVINGSTON CHIESA AMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2023
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N 9TH ST STE C
MODESTO CA
95350-5814
US

IV. Provider business mailing address

500 N 9TH ST STE C
MODESTO CA
95350-5814
US

V. Phone/Fax

Practice location:
  • Phone: 209-558-4420
  • Fax:
Mailing address:
  • Phone: 209-558-4420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number150603
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number134579
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: