Healthcare Provider Details

I. General information

NPI: 1437629276
Provider Name (Legal Business Name): MICHELE TENNYSON LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2018
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

182 S MAIN ST
GLEN CARBON IL
62034-1419
US

IV. Provider business mailing address

8 VALLEY VIEW DR
COLLINSVILLE IL
62234-6806
US

V. Phone/Fax

Practice location:
  • Phone: 618-952-2801
  • Fax:
Mailing address:
  • Phone: 618-952-2801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: