Provider Demographics
NPI:1043614803
Name:TIARKS, JOTHAM (LCPC)
Entity Type:Individual
Prefix:
First Name:JOTHAM
Middle Name:
Last Name:TIARKS
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 W SPRINGFIELD AVE
Mailing Address - Street 2:SUITE 605
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-6385
Mailing Address - Country:US
Mailing Address - Phone:217-722-9079
Mailing Address - Fax:217-501-4322
Practice Address - Street 1:201 W SPRINGFIELD AVE
Practice Address - Street 2:SUITE 605
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-6385
Practice Address - Country:US
Practice Address - Phone:217-722-9079
Practice Address - Fax:217-501-4322
Is Sole Proprietor?:No
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional