Provider Demographics
NPI:1689200834
Name:MASSAQUOI, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:MASSAQUOI
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 1:55 VALLE VISTA AVE APT 1005
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-3142
Mailing Address - Country:US
Mailing Address - Phone:707-655-6880
Mailing Address - Fax:
Practice Address - Street 1:1811 GRAND CANAL BLVD STE 2
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-8107
Practice Address - Country:US
Practice Address - Phone:209-707-5679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-19
Last Update Date:2021-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician