Provider Demographics
NPI:1629228515
Name:GIRARD, CARLY JEAN (AUD)
Entity Type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:JEAN
Last Name:GIRARD
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:MS
Other - First Name:CARLY
Other - Middle Name:JEAN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:35 TOWER COURT
Mailing Address - Street 2:STE. A
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031
Mailing Address - Country:US
Mailing Address - Phone:847-662-9300
Mailing Address - Fax:847-662-9360
Practice Address - Street 1:755 S. MILWAUKEE AVE.
Practice Address - Street 2:STE. 189
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048
Practice Address - Country:US
Practice Address - Phone:847-680-7580
Practice Address - Fax:847-680-9168
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-26
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147001294231H00000X
IL147.001294231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL207163001Medicare PIN