MEDICARE: CAROL J WILLOUGHBY CAROL WILLOUGHBY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	9875	NE

General Provider Information

NPI Number	:	1083954895
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROL J WILLOUGHBY CAROL WILLOUGHBY

Provider Business Mailing Address
First Line	:	656 S QUAIL LN
Second Line	:
City	:	COLUMBUS
State	:	NE
Zip	:	68601-6309
Country	:	US
Telephone Number	:	402-270-3195
Fax Number	:

Provider Business Practice Location Address
First Line	:	2363 18TH AVE
Second Line	:
City	:	COLUMBUS
State	:	NE
Zip	:	68601-2601
Country	:	US
Telephone Number	:	402-270-3195
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/15/2013
Last Update Date	:	02/15/2013

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