Provider Demographics
NPI:1104860238
Name:MILLER, TERESA KAY (MSW, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:KAY
Last Name:MILLER
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 284A
Mailing Address - Street 2:
Mailing Address - City:MC LEANSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62859-9785
Mailing Address - Country:US
Mailing Address - Phone:618-237-2906
Mailing Address - Fax:618-643-3128
Practice Address - Street 1:205 S SILAS AVE
Practice Address - Street 2:
Practice Address - City:MC LEANSBORO
Practice Address - State:IL
Practice Address - Zip Code:62859-1135
Practice Address - Country:US
Practice Address - Phone:618-237-2906
Practice Address - Fax:618-643-3128
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490054591041C0700X
IL13770751041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371358897OtherTRI-CARE NUMBER
IL03332001OtherBLUE CROSS NUMBER