Provider Demographics
NPI:1265120554
Name:FASOL, TARA CARLOTTA (LCPC)
Entity type:Individual
Prefix:DR
First Name:TARA
Middle Name:CARLOTTA
Last Name:FASOL
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11599 S COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:WEST FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:62896-4954
Mailing Address - Country:US
Mailing Address - Phone:618-923-5576
Mailing Address - Fax:
Practice Address - Street 1:218 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:62896-2406
Practice Address - Country:US
Practice Address - Phone:618-242-6944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180014503101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional