Provider Demographics
NPI:1619322468
Name:REX, CAROLYN
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:REX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:
Other - Last Name:PARKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 13008
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48901-3008
Mailing Address - Country:US
Mailing Address - Phone:517-364-1000
Mailing Address - Fax:517-364-6208
Practice Address - Street 1:363 FREMONT ST STE 203
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49017-3398
Practice Address - Country:US
Practice Address - Phone:269-969-6123
Practice Address - Fax:269-969-6122
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010638641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801063864OtherSTATE LICENSE