Provider Demographics
NPI:1861403511
Name:RISOLO, THERESA C (PSYD)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:C
Last Name:RISOLO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:MA
Mailing Address - Zip Code:01966-1411
Mailing Address - Country:US
Mailing Address - Phone:708-955-2806
Mailing Address - Fax:
Practice Address - Street 1:7055 VETERANS BLVD STE C
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-5641
Practice Address - Country:US
Practice Address - Phone:708-246-2637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-003688103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL 071-003688OtherLICENSE