1386157931 NPI number — THERESA REARDON DEWEY LCPC, ATR

Table of content: THERESA REARDON DEWEY LCPC, ATR (NPI 1386157931)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386157931 NPI number — THERESA REARDON DEWEY LCPC, ATR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEWEY
Provider First Name:
THERESA
Provider Middle Name:
REARDON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCPC, ATR
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:
1386157931
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2428 W GREENLEAF AVE UNIT 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60645-3304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-425-6892
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
725 WASHINGTON AVE
Provider Second Line Business Practice Location Address:
STE 108
Provider Business Practice Location Address City Name:
EVANSTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60202-2243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-442-2079
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/06/2017

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:  180009125 , 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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