Provider Demographics
NPI:1760848436
Name:LEWIS, TERETHA
Entity Type:Individual
Prefix:
First Name:TERETHA
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12627 S DIANE DR
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1229
Mailing Address - Country:US
Mailing Address - Phone:708-608-8917
Mailing Address - Fax:312-433-7935
Practice Address - Street 1:12627 S DIANE DR
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1229
Practice Address - Country:US
Practice Address - Phone:708-608-8917
Practice Address - Fax:312-433-7935
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-11
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490163171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical