Provider Demographics
NPI:1144276874
Name:ADELSTEIN, TEDDY (PHD)
Entity type:Individual
Prefix:
First Name:TEDDY
Middle Name:
Last Name:ADELSTEIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 PEREGRINE AVE
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-0170
Mailing Address - Country:US
Mailing Address - Phone:415-381-2209
Mailing Address - Fax:
Practice Address - Street 1:45 WINDSTONE DR
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-1438
Practice Address - Country:US
Practice Address - Phone:415-381-2209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 12543103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10769OtherSF CITY/COUNTY PROVIDER
CAOPL125430Medicare ID - Type Unspecified