Provider Demographics
NPI:1952040412
Name:CARR, KRISTEN RAE
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:RAE
Last Name:CARR
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 1:200 LAKESIDE CT APT 1424
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-7932
Mailing Address - Country:US
Mailing Address - Phone:815-529-6074
Mailing Address - Fax:
Practice Address - Street 1:1118 E MAIN ST # 2A
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2260
Practice Address - Country:US
Practice Address - Phone:815-529-6074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.107572104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker