Provider Demographics
NPI:1114210721
Name:KENNEDY PATTON, THERESA ANN (LCPC CRC LCAC LISAC)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:ANN
Last Name:KENNEDY PATTON
Suffix:
Gender:
Credentials:LCPC CRC LCAC LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 STEPHANIE CT
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-9279
Mailing Address - Country:US
Mailing Address - Phone:317-799-4343
Mailing Address - Fax:317-643-8989
Practice Address - Street 1:617 STEPHANIE CT
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IL
Practice Address - Zip Code:61571-9279
Practice Address - Country:US
Practice Address - Phone:317-799-4343
Practice Address - Fax:317-643-8989
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-16
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87001357A101YA0400X
TX16405101YA0400X
AZ15216101YA0400X
NC1804101YA0400X
IL180015238101YM0800X, 101YP2500X
IN204377225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1114210721OtherBLUE CROSS BLUE SHIELD
IL1114210721Medicaid