Provider Demographics
NPI:1801038765
Name:GOSCINSKI, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:GOSCINSKI
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 1:5409 WAKE FOREST DR
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-3970
Mailing Address - Country:US
Mailing Address - Phone:618-257-3497
Mailing Address - Fax:
Practice Address - Street 1:5409 WAKE FOREST DR
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-3970
Practice Address - Country:US
Practice Address - Phone:618-257-3497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-24
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490110391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical