Healthcare Provider Details

I. General information

NPI: 1407525702
Provider Name (Legal Business Name): NATHAN LEE CARON MHP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2021
Last Update Date: 12/27/2022
Certification Date: 12/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

988 N ILLINOIS ROUTE 3
WATERLOO IL
62298-1059
US

IV. Provider business mailing address

988 N ILLINOIS ROUTE 3
WATERLOO IL
62298-1059
US

V. Phone/Fax

Practice location:
  • Phone: 618-939-4444
  • Fax:
Mailing address:
  • Phone: 618-939-4444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: