=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124483060
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAITLYN MCCLURE MSW, LSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2015
-----------------------------------------------------
Last Update Date | 10/31/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 620 DAKOTA ST
-----------------------------------------------------
City | CRYSTAL LAKE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60012-3732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-721-0241
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7612 SOUTH DR
-----------------------------------------------------
City | WONDER LAKE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60097-9240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-790-1843
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------