Healthcare Provider Details

I. General information

NPI: 1144276874
Provider Name (Legal Business Name): TEDDY ADELSTEIN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 12/16/2021
Certification Date: 12/16/2021
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:
Mailing address:
  • Phone: 415-381-2209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 12543
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: