Provider Demographics
NPI:1407924004
Name:SOUDERS, TERESA A (LCSW)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:A
Last Name:SOUDERS
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 1:504 E 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:BRODHEAD
Mailing Address - State:WI
Mailing Address - Zip Code:53520-1106
Mailing Address - Country:US
Mailing Address - Phone:267-349-4816
Mailing Address - Fax:
Practice Address - Street 1:504 E 8TH AVE
Practice Address - Street 2:
Practice Address - City:BRODHEAD
Practice Address - State:WI
Practice Address - Zip Code:53520-1106
Practice Address - Country:US
Practice Address - Phone:267-349-4816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8718-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME098304OtherANTHEM LEGACY NUMBER
ME432407099Medicaid