Healthcare Provider Details

I. General information

NPI: 1649506858
Provider Name (Legal Business Name): TAMARA SUE HAYDEN MSED., LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2009
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 NE GLEN AVE STE 300
PEORIA IL
61606
US

IV. Provider business mailing address

120 NE GLEN AVE STE 300
PEORIA IL
61606
US

V. Phone/Fax

Practice location:
  • Phone: 309-672-4762
  • Fax:
Mailing address:
  • Phone: 309-672-4762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.000904
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: