Healthcare Provider Details

I. General information

NPI: 1336647171
Provider Name (Legal Business Name): TAMARA ALICE VODNANSKY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2018
Last Update Date: 01/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4920 E STATE ST
ROCKFORD IL
61108-2272
US

IV. Provider business mailing address

4920 E STATE ST
ROCKFORD IL
61108-2272
US

V. Phone/Fax

Practice location:
  • Phone: 815-227-9002
  • Fax: 815-227-9070
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149017238
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: