MEDICARE: TAMRA L COLDREN LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	149008366	IL

General Provider Information

NPI Number	:	1114919545
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMRA L COLDREN LCSW

Provider Business Mailing Address
First Line	:	PO BOX 790
Second Line	:
City	:	EDWARDSVILLE
State	:	IL
Zip	:	62025-0790
Country	:	US
Telephone Number	:	618-692-9640
Fax Number	:	618-692-9643

Provider Business Practice Location Address
First Line	:	103A SOUTH POINTE DRIVE
Second Line	:
City	:	EDWARDSVILLE
State	:	IL
Zip	:	62025-3780
Country	:	US
Telephone Number	:	618-656-2000
Fax Number	:	618-656-1169

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2005
Last Update Date	:	03/13/2012

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