Provider Demographics
NPI:1629949706
Name:TERESA, WILLIAM RICHARD
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:RICHARD
Last Name:TERESA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2402 4TH ST APT 4
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-3662
Mailing Address - Country:US
Mailing Address - Phone:310-995-6324
Mailing Address - Fax:
Practice Address - Street 1:4401 ELENDA ST
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-4101
Practice Address - Country:US
Practice Address - Phone:310-664-7788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-13
Last Update Date:2025-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program