Individual
ANDREA TACK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
3690 LAURA LN, ROCKFORD, IL 61114-8179
(815) 520-4145
Mailing address
123456 MAIN STREET, ROCKFORD, IL 61114-8179
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
Primary
150.015410
IL
Other
Enumeration date
08/31/2016
Last updated
06/30/2017
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