Provider Demographics
NPI:1063693265
Name:SLAYTON, THERESA ANNE (LCSW)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:ANNE
Last Name:SLAYTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:656A N 36TH ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-4474
Mailing Address - Country:US
Mailing Address - Phone:765-449-1759
Mailing Address - Fax:765-449-1769
Practice Address - Street 1:656A N 36TH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4474
Practice Address - Country:US
Practice Address - Phone:765-449-1759
Practice Address - Fax:765-449-1769
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN340027491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical