Provider Demographics
NPI:1275104374
Name:TEETER, SARA (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:TEETER
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 1:2663 FARRAGUT DR STE B
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-1462
Mailing Address - Country:US
Mailing Address - Phone:217-546-4090
Mailing Address - Fax:
Practice Address - Street 1:2663 FARRAGUT DR STE B
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-1462
Practice Address - Country:US
Practice Address - Phone:217-546-4090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490135811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical