Healthcare Provider Details

I. General information

NPI: 1760958797
Provider Name (Legal Business Name): TAZWOOD MENTAL HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2018
Last Update Date: 10/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 S CHICAGO ST
LINCOLN IL
62656-2719
US

IV. Provider business mailing address

3248 VANDEVER AVE
PEKIN IL
61554-6257
US

V. Phone/Fax

Practice location:
  • Phone: 217-732-6865
  • Fax:
Mailing address:
  • Phone: 309-477-5552
  • Fax: 309-347-4264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DAVID MINGUS
Title or Position: CEO
Credential: LCPC, CRADC
Phone: 309-347-5579