MEDICARE: CAITLIN M CARMODY MS

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		WI

General Provider Information

NPI Number	:	1427507508
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAITLIN M CARMODY MS

Provider Business Mailing Address
First Line	:	1496 BELLEVUE ST STE 101
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54311-4205
Country	:	US
Telephone Number	:	920-784-2644
Fax Number	:	920-784-2655

Provider Business Practice Location Address
First Line	:	1496 BELLEVUE ST STE 101
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54311-4205
Country	:	US
Telephone Number	:	920-784-2644
Fax Number	:	920-784-2655

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

Provider Enumeration Date	:	09/29/2016
Last Update Date	:	09/29/2016

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