Provider Demographics
NPI:1588911754
Name:CHERN, THERESA MARY GABRIELLE (CTRS)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:MARY GABRIELLE
Last Name:CHERN
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:MARY ANN
Other - Last Name:ROY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CTRS
Mailing Address - Street 1:1433 6TH ST
Mailing Address - Street 2:APT F
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-2554
Mailing Address - Country:US
Mailing Address - Phone:310-488-1232
Mailing Address - Fax:
Practice Address - Street 1:1433 6TH ST
Practice Address - Street 2:APT F
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-2554
Practice Address - Country:US
Practice Address - Phone:310-488-1232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-07
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41502174400000X, 225800000X, 171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist
No174400000XOther Service ProvidersSpecialist
No171W00000XOther Service ProvidersContractor