Healthcare Provider Details

I. General information

NPI: 1235891946
Provider Name (Legal Business Name): CARLY LUSK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2021
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

681 LILLIE ST
ELGIN IL
60120-4469
US

IV. Provider business mailing address

3811 S WALLACE ST
CHICAGO IL
60609-1749
US

V. Phone/Fax

Practice location:
  • Phone: 804-814-7961
  • Fax:
Mailing address:
  • Phone: 804-814-7961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34011029A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149023828
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: