Healthcare Provider Details

I. General information

NPI: 1669864302
Provider Name (Legal Business Name): T. ADELSTEIN, PH.D., PSYCHOLOGIST, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2015
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 WINDSTONE DR
SAN RAFAEL CA
94903-1438
US

IV. Provider business mailing address

823 PEREGRINE AVE
DAVIS CA
95616-0170
US

V. Phone/Fax

Practice location:
  • Phone: 415-381-2209
  • Fax: 415-593-7789
Mailing address:
  • Phone: 415-381-2209
  • Fax: 415-593-7789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number12543
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number12543
License Number StateCA

VIII. Authorized Official

Name: TEDDY ADELSTEIN
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 415-381-2209