NPIMap

Organization Active NPI

Tazwood Mental Health Center, Inc.

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Pekin, IL
National Provider Identifier
1083671127
Registry record updated Jan 16, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Mental Health Clinic/Center (Including Community Mental Health Center)Taxonomy code 261QM0801X
License
04132 Issued in IL
Legal business name
TAZWOOD MENTAL HEALTH CENTER, INC.
Practice address
3248 Vandever Ave
Pekin, IL 61554
Phone
(309) 347-5522
Fax
(309) 347-4264
NPI assigned
May 1, 2006
Last updated
Jan 16, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 16, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dave Walter Mingus, LCPC
Title
Ceo
Phone
(309) 347-5579

Specialties & licenses 11

Specialty (taxonomy)CodeLicenseStatePrimary
Counselor 101Y00000X NU
Addiction (Substance Use Disorder) Counselor 101YA0400X NU
Mental Health Counselor 101YM0800X NU
Professional Counselor 101YP2500X NU
Social Worker 104100000X NU
Clinical Social Worker 1041C0700X NU
Registered Nurse 163W00000X NU
Psychiatry Physician 2084P0800X NU
Mental Health Clinic/Center (Including Community Mental Health Center) 261QM0801X 04132 IL Primary
Case Manager/Care Coordinator 171M00000X NU
Community/Behavioral Health Agency 251S00000X NU

Addresses

Primary practice location

3248 Vandever Ave
Pekin, IL 61554

Mailing address

3248 Vandever Ave
Pekin, IL 61554
Phone (309) 347-5522

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040108000963 IL Part B Supplier - Clinic/Group Practice 1850291741 Receives reassigned benefits from 18 practitioners
1 other NPI on this enrollment
Practice locations: East Peoria, IL; Eureka, IL; Pekin, IL

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Tazwood Mental Health Center Inc14 organizations share this tax ID, including this one

Other organizations with this tax ID 13

Organizations that report the same tax identification number in the National Provider Directory.

View all 13

Locations

111 W Washington St
Ste 230
East Peoria, IL 61611
Phone (309) 694-6462

Practitioners & affiliated clinicians

Practitioners 21

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 21

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1146441600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1484524800000",
    "number": "1083671127",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3248 VANDEVER AVE",
            "city": "PEKIN",
            "state": "IL",
            "postal_code": "61554",
            "telephone_number": "309-347-5522",
            "fax_number": "309-347-4264"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3248 VANDEVER AVE",
            "city": "PEKIN",
            "state": "IL",
            "postal_code": "61554",
            "telephone_number": "309-347-5522",
            "fax_number": "309-347-4264"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TAZWOOD MENTAL HEALTH CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-01",
        "last_updated": "2017-01-16",
        "status": "A",
        "authorized_official_last_name": "MINGUS",
        "authorized_official_first_name": "DAVE",
        "authorized_official_middle_name": "WALTER",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "309-347-5579",
        "authorized_official_credential": "LCPC"
    },
    "taxonomies": [
        {
            "code": "101Y00000X",
            "taxonomy_group": "",
            "desc": "Counselor",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "104100000X",
            "taxonomy_group": "",
            "desc": "Social Worker",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "163W00000X",
            "taxonomy_group": "",
            "desc": "Registered Nurse",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": "IL",
            "license": "04132",
            "primary": true
        },
        {
            "code": "171M00000X",
            "taxonomy_group": "",
            "desc": "Case Manager/Care Coordinator",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Pekin, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 16, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.