=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770853574
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THERESA N OTU LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2012
-----------------------------------------------------
Last Update Date | 08/31/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10117 74TH ST SUITE 100
-----------------------------------------------------
City | KENOSHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53142-7533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-697-8268
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7252 91ST AVE
-----------------------------------------------------
City | KENOSHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53142-8253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-412-4564
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 5157-125
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | KY-1567
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------