Healthcare Provider Details

I. General information

NPI: 1417614181
Provider Name (Legal Business Name): DAVID CARR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2021
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2960 CHARTRES ST
LA SALLE IL
61301-1031
US

IV. Provider business mailing address

3413 BEAVER TRL APT D
AURORA OH
44202-8523
US

V. Phone/Fax

Practice location:
  • Phone: 815-224-1610
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2022013042
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License NumberRN.430412
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209027877
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: