Healthcare Provider Details

I. General information

NPI: 1942307541
Provider Name (Legal Business Name): CAROL SCHREPFER COLBURN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2006
Last Update Date: 11/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 W OTTOWA
PAXTON IL
60957
US

IV. Provider business mailing address

PO BOX 162 1510 W OTTOWA
PAXTON IL
60957
US

V. Phone/Fax

Practice location:
  • Phone: 217-379-4302
  • Fax: 217-379-4306
Mailing address:
  • Phone: 217-379-4302
  • Fax: 217-379-4306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149008840
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: