Healthcare Provider Details

I. General information

NPI: 1801919022
Provider Name (Legal Business Name): CARLA EVONNE BOUC LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 03/28/2025
Certification Date: 03/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 S VIRGINIA AVE
BELLEVILLE IL
62220-3689
US

IV. Provider business mailing address

812 S VIRGINIA AVE
BELLEVILLE IL
62220-3689
US

V. Phone/Fax

Practice location:
  • Phone: 618-236-2482
  • Fax:
Mailing address:
  • Phone: 618-236-2482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number180013435
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: