Healthcare Provider Details

I. General information

NPI: 1669155230
Provider Name (Legal Business Name): TYRA MONAY PANION MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2023
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2545 W DIVERSEY AVE
CHICAGO IL
60647-7172
US

IV. Provider business mailing address

2545 W DIVERSEY AVE STE 214216
CHICAGO IL
60647-7172
US

V. Phone/Fax

Practice location:
  • Phone: 312-509-3113
  • Fax:
Mailing address:
  • Phone: 312-509-3113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.033429
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: