Provider Demographics
NPI:1114210721
Name:KENNEDY PATTON, THERESA ANN (LCPC CRC LCAC LISAC)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:ANN
Last Name:KENNEDY PATTON
Suffix:
Gender:F
Credentials:LCPC CRC LCAC LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3468 ANTHONY LN
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47803-2387
Mailing Address - Country:US
Mailing Address - Phone:812-660-6383
Mailing Address - Fax:317-643-8989
Practice Address - Street 1:3468 ANTHONY LN
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47803-2387
Practice Address - Country:US
Practice Address - Phone:812-660-6383
Practice Address - Fax:317-643-8989
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-16
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15216101YA0400X
NC1804101YA0400X
IN204377225C00000X
IL180015238101YM0800X
IN87001357A101YA0400X
TX16405101YA0400X
IL178018821101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1114210721OtherBLUE CROSS BLUE SHIELD
IL1114210721Medicaid