Healthcare Provider Details

I. General information

NPI: 1548852437
Provider Name (Legal Business Name): DAVID VACCARO MSW, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2021
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1006 S DIVISION ST
CARTERVILLE IL
62918-1539
US

IV. Provider business mailing address

109 CALIFORNIA ST PO BOX 577
CARTERVILLE IL
62918
US

V. Phone/Fax

Practice location:
  • Phone: 618-519-9200
  • Fax: 618-985-3774
Mailing address:
  • Phone: 618-519-9200
  • Fax: 618-985-4635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149022307
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: