Provider Demographics
NPI:1952694283
Name:SCHALLER, TERRA LYNN (LCSW)
Entity type:Individual
Prefix:
First Name:TERRA
Middle Name:LYNN
Last Name:SCHALLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TERRA
Other - Middle Name:LYNN
Other - Last Name:KERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:3248 VANDEVER AVE
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-6257
Mailing Address - Country:US
Mailing Address - Phone:309-477-5517
Mailing Address - Fax:
Practice Address - Street 1:3248 VANDEVER AVE
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-6257
Practice Address - Country:US
Practice Address - Phone:309-477-5517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-19
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IL149.0167521041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health