Provider Demographics
NPI:1437126083
Name:MONTFORD, CAROLYN R (PSYD PC)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:R
Last Name:MONTFORD
Suffix:
Gender:F
Credentials:PSYD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 CHURCH STREET
Mailing Address - Street 2:STE 414
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201
Mailing Address - Country:US
Mailing Address - Phone:773-968-6393
Mailing Address - Fax:847-332-2095
Practice Address - Street 1:636 CHURCH STREET
Practice Address - Street 2:STE 414
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201
Practice Address - Country:US
Practice Address - Phone:773-968-6393
Practice Address - Fax:847-332-2095
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILIL71006679103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK23224Medicare ID - Type Unspecified
ILK23223Medicare ID - Type Unspecified