Provider Demographics
NPI:1063822666
Name:MACOMBER, CAROLYN JOYCE (LPC)
Entity Type:Individual
Prefix:MISS
First Name:CAROLYN
Middle Name:JOYCE
Last Name:MACOMBER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 BROADWAY ST STE10
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-2762
Mailing Address - Country:US
Mailing Address - Phone:269-845-1505
Mailing Address - Fax:
Practice Address - Street 1:1011 BROADWAY ST STE 10
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2762
Practice Address - Country:US
Practice Address - Phone:269-485-1505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-05
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013902101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor