Provider Demographics
NPI:1558848390
Name:TOMLINSON, MANETTE
Entity Type:Individual
Prefix:
First Name:MANETTE
Middle Name:
Last Name:TOMLINSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 CASS ST STE 3
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-3208
Mailing Address - Country:US
Mailing Address - Phone:815-345-3100
Mailing Address - Fax:844-734-1259
Practice Address - Street 1:1301 PYOTT RD STE 101
Practice Address - Street 2:
Practice Address - City:LAKE IN THE HILLS
Practice Address - State:IL
Practice Address - Zip Code:60156-9795
Practice Address - Country:US
Practice Address - Phone:815-345-3400
Practice Address - Fax:844-734-1259
Is Sole Proprietor?:No
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.011739101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional