=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154274215
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RILEY TANNER LPC, MA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2026
-----------------------------------------------------
Last Update Date | 02/18/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9 JUNCTION DR W STE 3
-----------------------------------------------------
City | GLEN CARBON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62034-2931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-710-4123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 33 DORSET CT
-----------------------------------------------------
City | EDWARDSVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62025-3991
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-570-9546
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 178.019997
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------