Provider Demographics
NPI:1427453760
Name:RANDICH, THERESA L (BA MHP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:L
Last Name:RANDICH
Suffix:
Gender:F
Credentials:BA MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28W671 GARYS MILL RD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1564
Mailing Address - Country:US
Mailing Address - Phone:630-293-9860
Mailing Address - Fax:630-293-9861
Practice Address - Street 1:28W671 GARYS MILL RD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1564
Practice Address - Country:US
Practice Address - Phone:630-293-9860
Practice Address - Fax:630-293-9861
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-29
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IL180.011783101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health