1306969779 NPI number — MRS. TERESA SUSAN ROLTGEN LMFT

Table of content: MRS. TERESA SUSAN ROLTGEN LMFT (NPI 1306969779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306969779 NPI number — MRS. TERESA SUSAN ROLTGEN LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROLTGEN
Provider First Name:
TERESA
Provider Middle Name:
SUSAN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306969779
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 25852
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRESNO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93729-5852
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-262-2531
Provider Business Mailing Address Fax Number:
559-434-7404

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3114 WILLOW AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLOVIS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93612-4750
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-286-6907
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  MFC33391 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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