1841963915 NPI number — MS. THERESA MARIE VIDALON LCSW

Table of content: MS. THERESA MARIE VIDALON LCSW (NPI 1841963915)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841963915 NPI number — MS. THERESA MARIE VIDALON LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VIDALON
Provider First Name:
THERESA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
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:
1841963915
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6002 S. HALSTED STREET
Provider Second Line Business Mailing Address:
ATTN THERESA VIDALON
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60621
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-564-2315
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
47 W POLK ST STE 250
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60605-2765
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-564-2315
Provider Business Practice Location Address Fax Number:
312-564-2401
Provider Enumeration Date:
07/26/2021

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: 1041C0700X , with the licence number:  149.024279 , 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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