Healthcare Provider Details

I. General information

NPI: 1558545467
Provider Name (Legal Business Name): MRS. CARLA BECK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 12/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 S 3RD ST
ALTAMONT IL
62411-1102
US

IV. Provider business mailing address

12 S 3RD ST
ALTAMONT IL
62411-1102
US

V. Phone/Fax

Practice location:
  • Phone: 618-483-3062
  • Fax:
Mailing address:
  • Phone: 618-483-3062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License NumberCB87150998P
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: