Provider Demographics
NPI:1558724039
Name:DESARNO, TEILA (LCPC, CADC)
Entity Type:Individual
Prefix:
First Name:TEILA
Middle Name:
Last Name:DESARNO
Suffix:
Gender:F
Credentials:LCPC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:795 OREGON TRL
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:IL
Mailing Address - Zip Code:60172-1306
Mailing Address - Country:US
Mailing Address - Phone:630-825-8745
Mailing Address - Fax:
Practice Address - Street 1:525 DUNHAM RD
Practice Address - Street 2:SUITE 55
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1490
Practice Address - Country:US
Practice Address - Phone:630-825-8745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL30153101YA0400X
IL180.007855101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)