Provider Demographics
NPI:1942279427
Name:KREILEIN, THERISA J (LCSW ACSW)
Entity Type:Individual
Prefix:MS
First Name:THERISA
Middle Name:J
Last Name:KREILEIN
Suffix:
Gender:F
Credentials:LCSW ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5003 N RINKERS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IN
Mailing Address - Zip Code:47167-8659
Mailing Address - Country:US
Mailing Address - Phone:812-883-5274
Mailing Address - Fax:812-883-5274
Practice Address - Street 1:305 EAST WALNUT ST.
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IN
Practice Address - Zip Code:47167-8659
Practice Address - Country:US
Practice Address - Phone:812-883-5274
Practice Address - Fax:812-883-5274
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000140A1041C0700X, 103TC0700X
KY4121041C0700X
KY0343106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN890800Medicare PIN
IN890800Medicare ID - Type Unspecified