Healthcare Provider Details

I. General information

NPI: 1629586508
Provider Name (Legal Business Name): THERESA KRUEGER DE CARLI LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2018
Last Update Date: 01/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7500 W JONQUIL TER
NILES IL
60714-3106
US

IV. Provider business mailing address

7500 W JONQUIL TER
NILES IL
60714-3106
US

V. Phone/Fax

Practice location:
  • Phone: 847-922-9616
  • Fax:
Mailing address:
  • Phone: 847-922-9616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number149.019573
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.019573
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: