Healthcare Provider Details

I. General information

NPI: 1861968240
Provider Name (Legal Business Name): IMANI TALIAH HARRISON MA, LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2018
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 DEVONSHIRE DR STE C19
CHAMPAIGN IL
61820-7352
US

IV. Provider business mailing address

607 E TOMARAS AVE
SAVOY IL
61874-9418
US

V. Phone/Fax

Practice location:
  • Phone: 309-431-5381
  • Fax:
Mailing address:
  • Phone: 217-255-0346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180014137
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.014231
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.014137
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: