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NPI Code Detail

MEDICARE: CASEY WALTON TANNER LCPC

MEDICARE: CASEY WALTON TANNER LCPC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health Counselor178.013798IL
2101YM0800XMental Health Counselor180012644IL

General Provider Information

NPI Number : 1396238242
Entity Type Code : Individual
Provider Name (Legal Business Name) : CASEY WALTON TANNER LCPC
Provider Business Mailing Address
First Line : 4345 N OAKLEY AVE UNIT 2
Second Line :
City : CHICAGO
State : IL
Zip : 60618-1619
Country : US
Telephone Number : 847-849-9237
Fax Number :
Provider Business Practice Location Address
First Line : 3046 W ARMITAGE AVE APT 1
Second Line :
City : CHICAGO
State : IL
Zip : 60647-5935
Country : US
Telephone Number : 847-849-9237
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/14/2018
Last Update Date : 08/16/2021

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Directions to “ CASEY WALTON TANNER LCPC” Practice Location

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