Healthcare Provider Details

I. General information

NPI: 1073236915
Provider Name (Legal Business Name): TYRA SPANN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TYRA SMITH

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 N WOLF RD
WHEELING IL
60090-2922
US

IV. Provider business mailing address

210 N WOLF RD
WHEELING IL
60090-2922
US

V. Phone/Fax

Practice location:
  • Phone: 847-353-1500
  • Fax:
Mailing address:
  • Phone: 847-353-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberMSW012326
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150113537
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: