Healthcare Provider Details

I. General information

NPI: 1912823840
Provider Name (Legal Business Name): TD FEWKES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12627 W 143RD ST
HOMER GLEN IL
60491-8381
US

IV. Provider business mailing address

13021 S OAK CT
PALOS HEIGHTS IL
60463-1927
US

V. Phone/Fax

Practice location:
  • Phone: 708-203-3199
  • Fax:
Mailing address:
  • Phone: 708-203-3199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: TERESA A DAVIS-FEWKES
Title or Position: PROVIDER
Credential: LCPC
Phone: 708-203-3199