Active NPI
Theresa Clement Tisdale, PH.D.
- Clinical Psychologist
- Glendora, CA
National Provider Identifier
1629316682
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 18587
- Practice address
- 150 E Meda Ave
Suite 110
Glendora, CA 91741-2689 - Phone
- (626) 224-5204
- NPI assigned
- Jan 26, 2013
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychologist | 103T00000X | 18587 | CA | |
| Clinical Psychologist | 103TC0700X | 18587 | CA | Primary |
Addresses
Primary practice location
150 E Meda Ave
Suite 110
Glendora, CA 91741-2689
Mailing address
150 E Meda Ave
Suite 110
Glendora, CA 91741-2689
Phone (626) 224-5204
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Previously, effective Aug 22, 2022 through Aug 22, 2026
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 18587 | CA | MD | Speech-Language Pathologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1359158400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1359158400000",
"number": "1629316682",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "150 E MEDA AVE",
"address_2": "SUITE 110",
"city": "GLENDORA",
"state": "CA",
"postal_code": "917412689",
"telephone_number": "626-224-5204"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "150 E MEDA AVE",
"address_2": "SUITE 110",
"city": "GLENDORA",
"state": "CA",
"postal_code": "917412689",
"telephone_number": "626-224-5204"
}
],
"practiceLocations": [],
"basic": {
"last_name": "TISDALE",
"first_name": "THERESA",
"middle_name": "CLEMENT",
"name_prefix": "Dr.",
"credential": "PH.D.",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2013-01-26",
"last_updated": "2013-01-26",
"status": "A"
},
"taxonomies": [
{
"code": "103T00000X",
"taxonomy_group": "",
"desc": "Psychologist",
"state": "CA",
"license": "18587",
"primary": false
},
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "CA",
"license": "18587",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Glendora, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 26, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.