Provider Demographics
NPI:1912608332
Name:TOMLIN, SHANIQUA (LSW)
Entity Type:Individual
Prefix:
First Name:SHANIQUA
Middle Name:
Last Name:TOMLIN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:SHANIQUA
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:701 DEVONSHIRE DR
Mailing Address - Street 2:BUILDING C, STE. 123
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-7337
Mailing Address - Country:US
Mailing Address - Phone:217-239-6218
Mailing Address - Fax:
Practice Address - Street 1:701 DEVONSHIRE DR
Practice Address - Street 2:BUILDING C, STE. 123
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7337
Practice Address - Country:US
Practice Address - Phone:217-239-6218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.108497101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health