MEDICARE: MRS. TERESA ANN VISINTINE LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	149005801	IL

General Provider Information

NPI Number	:	1437302411
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TERESA ANN VISINTINE LCSW

Provider Business Mailing Address
First Line	:	9 JUNCTION DR W
Second Line	:
City	:	GLEN CARBON
State	:	IL
Zip	:	62034-2931
Country	:	US
Telephone Number	:	618-207-4018
Fax Number	:	618-205-3990

Provider Business Practice Location Address
First Line	:	9 JUNCTION DR W
Second Line	:
City	:	GLEN CARBON
State	:	IL
Zip	:	62034-2931
Country	:	US
Telephone Number	:	618-207-4018
Fax Number	:	618-205-3990

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2008
Last Update Date	:	09/21/2015

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