Provider Demographics
NPI:1235665274
Name:PARKER, CAROLYN (MA)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:PARKER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 LOYOLA DR
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-1276
Mailing Address - Country:US
Mailing Address - Phone:847-680-6488
Mailing Address - Fax:847-367-5997
Practice Address - Street 1:1113 S MILWAUKEE AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3758
Practice Address - Country:US
Practice Address - Phone:847-367-5991
Practice Address - Fax:847-367-5997
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178014752101Y00000X
IL180013659101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor