Provider Demographics
NPI:1578812483
Name:MCCRARY, CAROL LYNN
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:LYNN
Last Name:MCCRARY
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 1:521 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-3514
Mailing Address - Country:US
Mailing Address - Phone:618-322-6296
Mailing Address - Fax:618-532-8296
Practice Address - Street 1:521 E 2ND ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3514
Practice Address - Country:US
Practice Address - Phone:618-322-6296
Practice Address - Fax:618-532-8296
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL222Q00000XOtherEARLY INTERVENTION PROVIDER