Provider Demographics
NPI:1215483318
Name:PENNINGTON, TATIANA C (MA, LPC)
Entity type:Individual
Prefix:
First Name:TATIANA
Middle Name:C
Last Name:PENNINGTON
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:861 KIRKWOOD DR APT 6
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62712-6843
Mailing Address - Country:US
Mailing Address - Phone:217-816-1912
Mailing Address - Fax:
Practice Address - Street 1:2924 STANTON ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-4315
Practice Address - Country:US
Practice Address - Phone:217-585-9185
Practice Address - Fax:217-585-8522
Is Sole Proprietor?:No
Enumeration Date:2016-08-29
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health