Healthcare Provider Details

I. General information

NPI: 1669149134
Provider Name (Legal Business Name): DANIEL THOMAS FOUTCH APRN, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2021
Last Update Date: 03/21/2025
Certification Date: 03/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 N NEIL ST STE C
CHAMPAIGN IL
61820-3614
US

IV. Provider business mailing address

328 N NEIL ST STE C
CHAMPAIGN IL
61820-3614
US

V. Phone/Fax

Practice location:
  • Phone: 217-377-0299
  • Fax: 217-492-8588
Mailing address:
  • Phone: 217-377-0299
  • Fax: 217-492-8588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209023867
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: