MEDICARE: BARRY TAN

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	34782	IL
2	101YM0800X	Mental Health Counselor	180.012998	IL

General Provider Information

NPI Number	:	1679187868
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BARRY TAN

Provider Business Mailing Address
First Line	:	2215 W CARMEN AVE # 3
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-1819
Country	:	US
Telephone Number	:	708-401-0830
Fax Number	:

Provider Business Practice Location Address
First Line	:	345 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60610-1237
Country	:	US
Telephone Number	:	312-476-9064
Fax Number	:

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

Provider Enumeration Date	:	09/03/2020
Last Update Date	:	09/04/2020

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Directions to “ BARRY TAN ” Practice Location

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