Provider Demographics
NPI:1962793398
Name:TEDFORD, DEAN
Entity type:Individual
Prefix:MR
First Name:DEAN
Middle Name:
Last Name:TEDFORD
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 1:586 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:CA
Mailing Address - Zip Code:95971-9747
Mailing Address - Country:US
Mailing Address - Phone:530-283-2735
Mailing Address - Fax:530-283-3647
Practice Address - Street 1:711 E MAIN ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:CA
Practice Address - Zip Code:95971-9722
Practice Address - Country:US
Practice Address - Phone:530-283-2735
Practice Address - Fax:530-283-3647
Is Sole Proprietor?:No
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA03-073764101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)