Healthcare Provider Details

I. General information

NPI: 1043471246
Provider Name (Legal Business Name): TEAL ASHLEY KOZEL PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 04/17/2022
Certification Date: 04/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 CALIFORNIA DR
VACAVILLE CA
95687
US

IV. Provider business mailing address

914 MORLEY AVE
YUBA CITY CA
95991-4337
US

V. Phone/Fax

Practice location:
  • Phone: 707-453-7017
  • Fax:
Mailing address:
  • Phone: 415-686-8582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number21923
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: