Provider Demographics
NPI:1730533910
Name:LAWRENCE, THERESA (LSW)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 FOX DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-7236
Mailing Address - Country:US
Mailing Address - Phone:217-351-9744
Mailing Address - Fax:217-351-9746
Practice Address - Street 1:1801 FOX DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7236
Practice Address - Country:US
Practice Address - Phone:217-351-9744
Practice Address - Fax:217-351-9746
Is Sole Proprietor?:No
Enumeration Date:2016-04-14
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.102080104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker