Provider Demographics
NPI:1083747356
Name:CARROLL, CHERI (LCSW)
Entity Type:Individual
Prefix:
First Name:CHERI
Middle Name:
Last Name:CARROLL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 KAYS DR STE C
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-1979
Mailing Address - Country:US
Mailing Address - Phone:309-664-3130
Mailing Address - Fax:309-664-3528
Practice Address - Street 1:405 KAYS DR STE C
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-1979
Practice Address - Country:US
Practice Address - Phone:309-664-3130
Practice Address - Fax:309-664-3528
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490089611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK03169Medicare ID - Type Unspecified