1326525668 NPI number — TIFFANY D ALLEN LCPC

Table of content: HAROLD JOHN BURSTEIN MD PHD (NPI 1285603001)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326525668 NPI number — TIFFANY D ALLEN LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALLEN
Provider First Name:
TIFFANY
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HARRISON
Provider Other First Name:
TIFFANY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCPC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1326525668
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
109 CALIFORNIA ST, PO BOX 577
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARTERVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62918-0577
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-519-9200
Provider Business Mailing Address Fax Number:
618-985-4635

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 S LEWIS LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARBONDALE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62901-3547
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-519-9200
Provider Business Practice Location Address Fax Number:
618-519-9961
Provider Enumeration Date:
07/19/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  180.007588 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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