Healthcare Provider Details

I. General information

NPI: 1972343143
Provider Name (Legal Business Name): MADDISON CARR MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MADDISON VINYARD

II. Dates (important events)

Enumeration Date: 05/27/2024
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2930 MONTVALE DR STE E
SPRINGFIELD IL
62704-5376
US

IV. Provider business mailing address

902 W MAIN ST
WEST FRANKFORT IL
62896-2210
US

V. Phone/Fax

Practice location:
  • Phone: 217-717-4399
  • Fax:
Mailing address:
  • Phone: 618-326-2772
  • Fax: 618-937-1440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.022127
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: