Healthcare Provider Details

I. General information

NPI: 1447927405
Provider Name (Legal Business Name): NICOLE TELTOE RADT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2021
Last Update Date: 06/22/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2136 EL CAJON BLVD
SAN DIEGO CA
92104-1102
US

IV. Provider business mailing address

823 GATEWAY CENTER WAY
SAN DIEGO CA
92102-4541
US

V. Phone/Fax

Practice location:
  • Phone: 619-515-2588
  • Fax: 619-450-6267
Mailing address:
  • Phone: 619-515-2300
  • Fax: 619-237-1856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1426460421
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: