Provider Demographics
NPI:1114457850
Name:THE TABOR THERAPY GROUP, INC
Entity Type:Organization
Organization Name:THE TABOR THERAPY GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:TABOR
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:815-331-8768
Mailing Address - Street 1:5400 W ELM ST STE 104
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-4032
Mailing Address - Country:US
Mailing Address - Phone:815-331-8768
Mailing Address - Fax:815-331-8760
Practice Address - Street 1:5400 W ELM ST SUITE 104
Practice Address - Street 2:SUITE 104
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-6005
Practice Address - Country:US
Practice Address - Phone:815-331-8768
Practice Address - Fax:815-331-8768
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE TABOR THERAPY GROUP, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-15
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060012029261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2B17-IPI-002Medicaid