Provider Demographics
NPI:1326567371
Name:WILLMORE, TAMARA LANE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:LANE
Last Name:WILLMORE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 S BINKLEY ST
Mailing Address - Street 2:
Mailing Address - City:WEST FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:62896-3007
Mailing Address - Country:US
Mailing Address - Phone:618-932-8559
Mailing Address - Fax:
Practice Address - Street 1:409 E PARK ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:IL
Practice Address - Zip Code:62812-1920
Practice Address - Country:US
Practice Address - Phone:618-439-7231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-11
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146005821235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1609901784Medicaid