| Doctor Name: | JOTHAM TIARKS |
| NPI Number: | 1043614803 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | LCPC |
| License Number: | |
| Business Practice Address: | 201 W Springfield Ave Suite 605 Champaign, IL - 618206385 |
| Business Phone Number: | 2177229079 |
| Business Fax Number: | 2175014322 |
| Mailing Address: | 201 W Springfield Ave, Suite 605 CHAMPAIGN |
| State: | IL |
| Postal Code: | 618206385 |
| Phone Number: | 2177229079 |
| Fax Number: | 2175014322 |
| NPI Enumeration Date: | 10/22/2014 |
| NPI Last Update Date: | 10/22/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YP2500X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Professional |
| Taxonomy Definition: | |