1619174489 NPI number — MRS. HEATHER L TETEAK-BERG LCPC, NCC, CCTP

Table of content: NICOLE BLAY APRN (NPI 1740936970)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619174489 NPI number — MRS. HEATHER L TETEAK-BERG LCPC, NCC, CCTP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TETEAK-BERG
Provider First Name:
HEATHER
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCPC, NCC, CCTP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619174489
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2244 95TH ST UNIT 218
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NAPERVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60564-8033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-677-1849
Provider Business Mailing Address Fax Number:
630-717-1165

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2244 95TH ST UNIT 218
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAPERVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60564-8033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-677-1849
Provider Business Practice Location Address Fax Number:
630-717-1165
Provider Enumeration Date:
06/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  180-000428 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02232187 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 28872 . This is a "NCC" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 211652 . This is a "EVERGREEN CERTIFICATIONS--CERTIFIED CLINICAL TRAUMA PROFESSIONAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 180-000428 . This is a "LCPC" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: S-1163 . This is a "ASSOCIATION FOR PLAY THERAPY" identifier . This identifiers is of the category "OTHER".




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