Healthcare Provider Details

I. General information

NPI: 1053624098
Provider Name (Legal Business Name): JOHN C CARTER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2010
Last Update Date: 08/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 W JACKSON BLVD 1257
CHICAGO IL
60604-3606
US

IV. Provider business mailing address

53 W JACKSON BLVD 1257
CHICAGO IL
60604-3606
US

V. Phone/Fax

Practice location:
  • Phone: 312-360-1983
  • Fax: 312-360-1984
Mailing address:
  • Phone: 312-360-1983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149014243
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: