Provider Demographics
NPI:1790716694
Name:CARR, CONSTANCE (MSW)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:
Last Name:CARR
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2619 ELISHA AVE
Mailing Address - Street 2:
Mailing Address - City:ZION
Mailing Address - State:IL
Mailing Address - Zip Code:60099-0603
Mailing Address - Country:US
Mailing Address - Phone:847-746-0400
Mailing Address - Fax:847-746-0403
Practice Address - Street 1:2619 ELISHA AVE
Practice Address - Street 2:
Practice Address - City:ZION
Practice Address - State:IL
Practice Address - Zip Code:60099-0603
Practice Address - Country:US
Practice Address - Phone:847-746-0400
Practice Address - Fax:847-746-0403
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1509-125101YP2500X
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43579700Medicaid