Healthcare Provider Details

I. General information

NPI: 1487701793
Provider Name (Legal Business Name): TAMMY R THIEME LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2428 CHARTRES ST
LA SALLE IL
61301-1107
US

IV. Provider business mailing address

PO BOX 1488 2960 CHARTRES STREET
LA SALLE IL
61301-3488
US

V. Phone/Fax

Practice location:
  • Phone: 815-780-8765
  • Fax:
Mailing address:
  • Phone: 815-224-1610
  • Fax: 815-223-1634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.007435
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: