Provider Demographics
NPI:1508464330
Name:MUGERDITCHIAN, THERESA (MSW, PEL)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:MUGERDITCHIAN
Suffix:
Gender:F
Credentials:MSW, PEL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N MIDLOTHIAN RD
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-1146
Mailing Address - Country:US
Mailing Address - Phone:847-949-2712
Mailing Address - Fax:
Practice Address - Street 1:1200 N MIDLOTHIAN RD
Practice Address - Street 2:
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-1146
Practice Address - Country:US
Practice Address - Phone:847-949-2712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
IL26247751041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No104100000XBehavioral Health & Social Service ProvidersSocial Worker