Provider Demographics
NPI:1639240211
Name:SULT, TERESA ANN (LCSW, CSAT)
Entity Type:Individual
Prefix:MS
First Name:TERESA
Middle Name:ANN
Last Name:SULT
Suffix:
Gender:F
Credentials:LCSW, CSAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 LINCOLN WAY EAST
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-2016
Mailing Address - Country:US
Mailing Address - Phone:574-255-4976
Mailing Address - Fax:574-255-1882
Practice Address - Street 1:113 LINCOLN WAY EAST
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-2016
Practice Address - Country:US
Practice Address - Phone:574-255-4976
Practice Address - Fax:574-255-1882
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN457535000OtherMAGELLAN
IN200475040Medicaid
IN400572OtherTRI-CARE
IN400572OtherMHN
IN000000341226OtherANTHEM