| Doctor Name: | RANDALL S TENNIS |
| NPI Number: | 1174588792 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | CADC |
| License Number: | 5435 |
| Business Practice Address: | 3248 Vandever Ave Pekin, IL - 61554 |
| Business Phone Number: | 3093475522 |
| Business Fax Number: | 3093474264 |
| Mailing Address: | 3248 Vandever Ave, PEKIN |
| State: | IL |
| Postal Code: | 61554 |
| Phone Number: | 3093475522 |
| Fax Number: | 3093474264 |
| NPI Enumeration Date: | 04/18/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | 5435 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |