Provider Demographics
NPI:1588211775
Name:FLETCHER, THERESE GOTTFREID (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:GOTTFREID
Last Name:FLETCHER
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 MARENGO AVE UNIT 103
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-1316
Mailing Address - Country:US
Mailing Address - Phone:708-267-1272
Mailing Address - Fax:
Practice Address - Street 1:140 MARENGO AVE
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-1379
Practice Address - Country:US
Practice Address - Phone:708-267-1272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490180201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical