Healthcare Provider Details

I. General information

NPI: 1508805086
Provider Name (Legal Business Name): KATHLEEN ANN CARTER L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 05/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 N 12TH ST
QUINCY IL
62301-1355
US

IV. Provider business mailing address

1118 MARIA CT
QUINCY IL
62305-7147
US

V. Phone/Fax

Practice location:
  • Phone: 217-222-8641
  • Fax:
Mailing address:
  • Phone: 217-617-8337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149006508
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: