Healthcare Provider Details

I. General information

NPI: 1760508907
Provider Name (Legal Business Name): TAZWOOD MENTAL HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 07/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W. WASHINGTON STREET SUITE 230
EAST PEORIA IL
61611
US

IV. Provider business mailing address

3248 VANDEVER AVE
PEKIN IL
61554-6257
US

V. Phone/Fax

Practice location:
  • Phone: 309-694-6462
  • Fax: 309-694-7812
Mailing address:
  • Phone: 309-347-5579
  • Fax: 309-347-4264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DAVE WALTER MINGUS
Title or Position: CEO
Credential: LCPC
Phone: 309-347-5579