MEDICARE: MRS. BARB GRACE ELAM LCPC

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	101YP2500X	Professional Counselor	180001421	IL

General Provider Information

NPI Number	:	1447273412
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BARB GRACE ELAM LCPC

Provider Business Mailing Address
First Line	:	139 PINE SHORE DR # 37
Second Line	:
City	:	CARBONDALE
State	:	IL
Zip	:	62902
Country	:	US
Telephone Number	:	618-529-3900
Fax Number	:	618-529-0194

Provider Business Practice Location Address
First Line	:	139 PINE SHORE DR # 37
Second Line	:
City	:	CARBONDALE
State	:	IL
Zip	:	62902-7503
Country	:	US
Telephone Number	:	618-529-3900
Fax Number	:	618-529-0194

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

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	04/20/2017

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