Provider Demographics
NPI:1508475849
Name:LITTLE, CAROLYN
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:LITTLE
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:PO BOX 1109
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-7109
Mailing Address - Country:US
Mailing Address - Phone:815-766-3308
Mailing Address - Fax:815-756-2944
Practice Address - Street 1:1325 SYCAMORE RD
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-2483
Practice Address - Country:US
Practice Address - Phone:815-758-8616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-22
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL474579189001Medicaid