Provider Demographics
NPI:1447584248
Name:WILLARD, CARLY J
Entity Type:Individual
Prefix:MS
First Name:CARLY
Middle Name:J
Last Name:WILLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-9562
Mailing Address - Country:US
Mailing Address - Phone:815-288-6256
Mailing Address - Fax:
Practice Address - Street 1:98 S GALENA AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-3034
Practice Address - Country:US
Practice Address - Phone:815-285-1812
Practice Address - Fax:815-285-1833
Is Sole Proprietor?:No
Enumeration Date:2009-09-25
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health