Healthcare Provider Details

I. General information

NPI: 1942995675
Provider Name (Legal Business Name): TARYN ELLISON LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 E MADISON ST STE 1F
SPRINGFIELD IL
62701-3118
US

IV. Provider business mailing address

PO BOX 19639
SPRINGFIELD IL
62794-9639
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax: 217-757-8161
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-545-2101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number180.015030
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180015030
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.015030
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: