Basic Information
| Provider Information | |||||||||
| NPI: | 1265059463 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TEBODA | ||||||||
| FirstName: | MCKENNA | ||||||||
| MiddleName: | TERESE | ||||||||
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| Credential: | LPC, NCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 742 ESSINGTON RD | ||||||||
| Address2: | |||||||||
| City: | JOLIET | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604354912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157292160 | ||||||||
| FaxNumber: | 8153730099 | ||||||||
| Practice Location | |||||||||
| Address1: | 742 ESSINGTON RD | ||||||||
| Address2: | |||||||||
| City: | JOLIET | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604354912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157292160 | ||||||||
| FaxNumber: | 8153730099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2020 | ||||||||
| LastUpdateDate: | 03/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.