Provider Demographics
NPI:1003595463
Name:TEVAULT, AMY (MA, LPC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:TEVAULT
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 E WACKER DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-5212
Mailing Address - Country:US
Mailing Address - Phone:312-600-3935
Mailing Address - Fax:
Practice Address - Street 1:303 E WACKER DR STE 1130
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-5227
Practice Address - Country:US
Practice Address - Phone:312-600-3935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.019198101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health