=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437468345
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TERESA REICHART-VERNON, LSCSW LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2010
-----------------------------------------------------
Last Update Date | 09/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10601 KAW DR STE. B
-----------------------------------------------------
City | EDWARDSVILLE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66111-1130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-207-7674
-----------------------------------------------------
Fax | 913-745-8040
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10601 KAW DR STE. B
-----------------------------------------------------
City | EDWARDSVILLE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66111-1130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-207-7674
-----------------------------------------------------
Fax | 913-745-8040
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TERESA REICHART-VERNON
-----------------------------------------------------
Credential | LSCSW
-----------------------------------------------------
Telephone | 913-207-7674
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LSCSW 1463
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------