Healthcare Provider Details

I. General information

NPI: 1619929445
Provider Name (Legal Business Name): TERESA MARIE GEORGE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 02/28/2022
Certification Date: 02/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3925 IMEL RD
SAN LUIS OBISPO CA
93401-6238
US

IV. Provider business mailing address

3940-7 BROAD STREET, PMB #305
SAN LUIS OBISPO CA
93401
US

V. Phone/Fax

Practice location:
  • Phone: 805-710-3199
  • Fax: 805-262-6206
Mailing address:
  • Phone: 805-971-0131
  • Fax: 805-926-2162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPSY16121
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY16121
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: