Provider Demographics
NPI:1538388426
Name:IDEHEN, TEDDY (BSC, COUNSELOR)
Entity type:Individual
Prefix:MR
First Name:TEDDY
Middle Name:
Last Name:IDEHEN
Suffix:
Gender:M
Credentials:BSC, COUNSELOR
Other - Prefix:
Other - First Name:TEDDY
Other - Middle Name:
Other - Last Name:IDEHEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BSC, COUNSELOR
Mailing Address - Street 1:11633 HAWTHORNE BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-2322
Mailing Address - Country:US
Mailing Address - Phone:310-351-9295
Mailing Address - Fax:
Practice Address - Street 1:11633 HAWTHORNE BLVD STE 210
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-2322
Practice Address - Country:US
Practice Address - Phone:310-351-9295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARI-10509270844101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARI-10509270844OtherADDICTION COUNSELOR