Provider Demographics
NPI:1396783866
Name:MCDANIEL MOSSMAN, TAMI (LCPC, CADC)
Entity type:Individual
Prefix:
First Name:TAMI
Middle Name:
Last Name:MCDANIEL MOSSMAN
Suffix:
Gender:F
Credentials:LCPC, CADC
Other - Prefix:
Other - First Name:TAMI
Other - Middle Name:
Other - Last Name:MCDANIEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCPC CADC
Mailing Address - Street 1:1217 LARCHMONT DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-2109
Mailing Address - Country:US
Mailing Address - Phone:217-793-8338
Mailing Address - Fax:
Practice Address - Street 1:801 S GRAND AVE W
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-3640
Practice Address - Country:US
Practice Address - Phone:217-502-9120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180004510101YP2500X
IL13042101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)