Provider Demographics
NPI:1558849323
Name:RAGSDALE, KARLA JAYNE (LCPC)
Entity Type:Individual
Prefix:
First Name:KARLA
Middle Name:JAYNE
Last Name:RAGSDALE
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:KARLA
Other - Middle Name:JAYNE
Other - Last Name:STINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1161 FORTUNE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:SHILOH
Mailing Address - State:IL
Mailing Address - Zip Code:62269-7385
Mailing Address - Country:US
Mailing Address - Phone:618-314-0547
Mailing Address - Fax:
Practice Address - Street 1:1161 FORTUNE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-7385
Practice Address - Country:US
Practice Address - Phone:618-314-0547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-02
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180012510101YM0800X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1558849323OtherNPI