1619328341 NPI number — TERESA MARKUM LCPC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619328341 NPI number — TERESA MARKUM LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARKUM
Provider First Name:
TERESA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCPC
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:
1619328341
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5824 WALNUT AVE
Provider Second Line Business Mailing Address:
APT 2C
Provider Business Mailing Address City Name:
DOWNERS GROVE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60516-6015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-258-8851
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4300 COMMERCE CT
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
LISLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60532-3709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-258-8851
Provider Business Practice Location Address Fax Number:
872-228-8139
Provider Enumeration Date:
06/23/2016

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:  180010256 , 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)





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