Provider Demographics
NPI:1003423674
Name:EWING, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:EWING
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 1:503 GARDEN CIR
Mailing Address - Street 2:
Mailing Address - City:STREAMWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60107-6896
Mailing Address - Country:US
Mailing Address - Phone:815-245-3707
Mailing Address - Fax:
Practice Address - Street 1:503 GARDEN CIR
Practice Address - Street 2:
Practice Address - City:STREAMWOOD
Practice Address - State:IL
Practice Address - Zip Code:60107-6896
Practice Address - Country:US
Practice Address - Phone:815-245-3707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490187551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical