Provider Demographics
NPI:1972295517
Name:MAIDAK, TERESA NAN (LCSW)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:NAN
Last Name:MAIDAK
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 1:2511 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:THOMSON
Mailing Address - State:IL
Mailing Address - Zip Code:61285-8525
Mailing Address - Country:US
Mailing Address - Phone:815-718-0237
Mailing Address - Fax:
Practice Address - Street 1:2511 MARKET ST
Practice Address - Street 2:
Practice Address - City:THOMSON
Practice Address - State:IL
Practice Address - Zip Code:61285-8525
Practice Address - Country:US
Practice Address - Phone:815-718-0237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0127391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical