Provider Demographics
NPI:1376503177
Name:BUSSERT, THERESA A (LCSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:BUSSERT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 S NAPERVILLE RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-8155
Mailing Address - Country:US
Mailing Address - Phone:630-653-6441
Mailing Address - Fax:630-653-8409
Practice Address - Street 1:1725 S NAPERVILLE RD
Practice Address - Street 2:SUITE 206
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-8155
Practice Address - Country:US
Practice Address - Phone:630-653-6441
Practice Address - Fax:630-653-8409
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0110561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209551OtherGROUP NUMBER
IL209551OtherGROUP NUMBER