Provider Demographics
NPI:1528201423
Name:KISH, THERESA LYNNE (LCPC)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:LYNNE
Last Name:KISH
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 W VETERANS PKWY
Mailing Address - Street 2:SUITE D
Mailing Address - City:YORKVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60560-4567
Mailing Address - Country:US
Mailing Address - Phone:630-552-5643
Mailing Address - Fax:630-689-1161
Practice Address - Street 1:624 W VETERANS PKWY
Practice Address - Street 2:SUITE D
Practice Address - City:YORKVILLE
Practice Address - State:IL
Practice Address - Zip Code:60560-4567
Practice Address - Country:US
Practice Address - Phone:630-552-5643
Practice Address - Fax:630-689-1161
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-08
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-002412101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional