Healthcare Provider Details

I. General information

NPI: 1114210721
Provider Name (Legal Business Name): THERESA ANN KENNEDY PATTON LCPC CRC LPC LCAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2011
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

617 STEPHANIE CT
WASHINGTON IL
61571-9279
US

IV. Provider business mailing address

617 STEPHANIE CT
WASHINGTON IL
61571-9279
US

V. Phone/Fax

Practice location:
  • Phone: 317-799-4343
  • Fax: 317-643-8989
Mailing address:
  • Phone: 317-799-4343
  • Fax: 317-643-8989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1804
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15216
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180015238
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number204377
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number87001357A
License Number StateIN
# 6
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11965125
License Number StateWI
# 7
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number23605
License Number StateAZ
# 8
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16405
License Number StateTX
# 9
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2025015218
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: