Provider Demographics
NPI:1952651846
Name:KENT, TERESA ANN (LCSW, ACSW)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:ANN
Last Name:KENT
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:PO BOX 1105
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1105
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:
Practice Address - Street 1:405 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1462
Practice Address - Country:US
Practice Address - Phone:618-457-3024
Practice Address - Fax:618-985-1318
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490015461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149001546OtherSTATE OF ILLINOIS
IL214881OtherMEDICARE GROUP PTAN