Provider Demographics
NPI:1023365350
Name:DE LA FUENTE, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:DE LA FUENTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 E JEFFERSON AVE STE 202B
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-8405
Mailing Address - Country:US
Mailing Address - Phone:415-574-7176
Mailing Address - Fax:
Practice Address - Street 1:43 E JEFFERSON AVE STE 202B
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-8405
Practice Address - Country:US
Practice Address - Phone:347-921-2175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-06
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA77981106H00000X
IL166.001309106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health