Provider Demographics
NPI:1679558571
Name:TANTILLO, MICHELE L (LCSW)
Entity type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:L
Last Name:TANTILLO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:357 MEADOWLARK DR
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4980
Mailing Address - Country:US
Mailing Address - Phone:847-338-8268
Mailing Address - Fax:847-338-8268
Practice Address - Street 1:357 MEADOWLARK DRIVE
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440
Practice Address - Country:US
Practice Address - Phone:847-338-8268
Practice Address - Fax:847-338-8268
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149007488104100000X
IL149.0074881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker