Basic Information
Provider Information | |||||||||
NPI: | 1629444070 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TAZWOOD MENTAL HEALTH CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TAZWOOD CENTER FOR WELLNESS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 210 W WALNUT ST | ||||||||
Address2: |   | ||||||||
City: | CANTON | ||||||||
State: | IL | ||||||||
PostalCode: | 615202444 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3096475240 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 210 W. WALNUT STREET | ||||||||
Address2: |   | ||||||||
City: | CANTON | ||||||||
State: | IL | ||||||||
PostalCode: | 615202444 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3096475240 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/19/2015 | ||||||||
LastUpdateDate: | 08/19/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FRANKLIN | ||||||||
AuthorizedOfficialFirstName: | N | ||||||||
AuthorizedOfficialMiddleName: | BRENDA | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 3094775526 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | TAZWOOD MENTAL HEALTH CENTER, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 04132 | IL | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.