Provider Demographics
NPI:1952475659
Name:BRANDON, CAROLYN RUTH (PHD, LCPC)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:RUTH
Last Name:BRANDON
Suffix:
Gender:F
Credentials:PHD, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 S PARK AVE
Mailing Address - Street 2:D
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-4128
Mailing Address - Country:US
Mailing Address - Phone:618-988-1757
Mailing Address - Fax:
Practice Address - Street 1:1220 S PARK AVE
Practice Address - Street 2:D
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-4128
Practice Address - Country:US
Practice Address - Phone:618-988-1757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL265493Medicare UPIN
IL406286Medicare UPIN
IL045869Medicare UPIN
IL5911313Medicare UPIN