Provider Demographics
NPI:1588317333
Name:STORY, THERESA MARIE
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:STORY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3715 COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93306-2719
Mailing Address - Country:US
Mailing Address - Phone:661-868-7166
Mailing Address - Fax:
Practice Address - Street 1:3715 COLUMBUS ST
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93306-2719
Practice Address - Country:US
Practice Address - Phone:661-868-1823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-01
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 390200000X
CA137802106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty