Provider Demographics
NPI:1477250595
Name:PANEK, TIESHA RIANN (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:TIESHA
Middle Name:RIANN
Last Name:PANEK
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3203 THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:WONDER LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60097-8242
Mailing Address - Country:US
Mailing Address - Phone:815-276-5741
Mailing Address - Fax:
Practice Address - Street 1:10 W MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:IL
Practice Address - Zip Code:60013-2868
Practice Address - Country:US
Practice Address - Phone:815-526-3781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2090267922084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry