Provider Demographics
NPI:1942544168
Name:KAMPWERTH, TINA MARIE (LCPC)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:MARIE
Last Name:KAMPWERTH
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:MARIE
Other - Last Name:HOLTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LCPC
Mailing Address - Street 1:8031 JOSEPH COURT
Mailing Address - Street 2:
Mailing Address - City:SAINT ROSE
Mailing Address - State:IL
Mailing Address - Zip Code:62230-2506
Mailing Address - Country:US
Mailing Address - Phone:618-795-0630
Mailing Address - Fax:
Practice Address - Street 1:1161 FORTUNE BLVD STE 400
Practice Address - Street 2:SUITE 400
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-7385
Practice Address - Country:US
Practice Address - Phone:618-795-0630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2017-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180008432101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional