Provider Demographics
NPI:1033667167
Name:PETERSON, TECYA (LSW)
Entity Type:Individual
Prefix:
First Name:TECYA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 W WASHINGTON BLVD
Mailing Address - Street 2:SUITE 113
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-2203
Mailing Address - Country:US
Mailing Address - Phone:815-418-6070
Mailing Address - Fax:779-803-0169
Practice Address - Street 1:2081 CALISTOGA DR
Practice Address - Street 2:SUITE #2S
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-4831
Practice Address - Country:US
Practice Address - Phone:815-418-6070
Practice Address - Fax:779-803-0169
Is Sole Proprietor?:No
Enumeration Date:2016-09-19
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.101723104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL150.101723OtherLICENSE