Provider Demographics
NPI:1164906970
Name:VERSACI, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:VERSACI
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 1:525 TYLER RD STE Q1
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-3360
Mailing Address - Country:US
Mailing Address - Phone:630-444-0077
Mailing Address - Fax:
Practice Address - Street 1:525 TYLER RD STE Q1
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-3360
Practice Address - Country:US
Practice Address - Phone:630-444-0077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242005015235Z00000X
IL146014764235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist