Provider Demographics
NPI:1215502299
Name:HERBORD, TARA (LCPC)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:HERBORD
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 1:159 BEYERS LAKE EST
Mailing Address - Street 2:
Mailing Address - City:PANA
Mailing Address - State:IL
Mailing Address - Zip Code:62557-9702
Mailing Address - Country:US
Mailing Address - Phone:217-851-8330
Mailing Address - Fax:
Practice Address - Street 1:159 BEYERS LAKE EST
Practice Address - Street 2:
Practice Address - City:PANA
Practice Address - State:IL
Practice Address - Zip Code:62557-9702
Practice Address - Country:US
Practice Address - Phone:217-851-8330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-23
Last Update Date:2021-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.003829101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional