Healthcare Provider Details

I. General information

NPI: 1669036489
Provider Name (Legal Business Name): DAVID MCDANIEL LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2019
Last Update Date: 01/07/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 TRADE CENTRE DR STE 302
CHAMPAIGN IL
61820-7233
US

IV. Provider business mailing address

100 TRADE CENTRE DR STE 302
CHAMPAIGN IL
61820-7233
US

V. Phone/Fax

Practice location:
  • Phone: 217-731-4638
  • Fax:
Mailing address:
  • Phone: 217-731-4638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.024629
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150.10375
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: