Provider Demographics
NPI:1417185414
Name:KILGORE, THERESE H (MC, LPC)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:H
Last Name:KILGORE
Suffix:
Gender:F
Credentials:MC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 S POWER RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-6686
Mailing Address - Country:US
Mailing Address - Phone:480-656-0500
Mailing Address - Fax:480-656-1034
Practice Address - Street 1:2500 S POWER RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-6686
Practice Address - Country:US
Practice Address - Phone:480-656-0500
Practice Address - Fax:480-656-1034
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-29
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-13029101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional