Individual
THERESA DEWALT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
1220 MOUND AVE STE 304, RACINE, WI 53404-3350
(262) 488-0011
Mailing address
1220 MOUND AVE STE 304, RACINE, WI 53404-3350
(262) 488-0011
Taxonomy
Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
Primary
3369-125
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
40978600
—
WI
Enumeration date
05/31/2008
Last updated
05/31/2008
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