Provider Demographics
NPI:1598886103
Name:CARROCCIA, EUGENE S (PSYD)
Entity Type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:S
Last Name:CARROCCIA
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:DR
Other - First Name:GENE
Other - Middle Name:
Other - Last Name:CARROCCIA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 776
Mailing Address - Street 2:ADVOCATE FAMILY CARE NETWORK
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60454-0776
Mailing Address - Country:US
Mailing Address - Phone:800-216-1110
Mailing Address - Fax:708-346-4868
Practice Address - Street 1:4700 W 95TH ST
Practice Address - Street 2:SUITE LL5
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2533
Practice Address - Country:US
Practice Address - Phone:800-216-1110
Practice Address - Fax:708-346-4868
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-006067103TB0200X, 103TC0700X, 103TC2200X, 103TF0000X, 103TA0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK04142Medicare ID - Type Unspecified
ILQ08538Medicare UPIN