Provider Demographics
NPI:1013135011
Name:ENDICOTT, CAROLYN SUE (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:SUE
Last Name:ENDICOTT
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:MRS
Other - First Name:CAROLYN
Other - Middle Name:SUE
Other - Last Name:PLOG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW, LCSW
Mailing Address - Street 1:2900 FRANK SCOTT PKWY W
Mailing Address - Street 2:SUITE 956
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-5000
Mailing Address - Country:US
Mailing Address - Phone:618-233-3273
Mailing Address - Fax:618-234-7233
Practice Address - Street 1:2900 FRANK SCOTT PKWY W
Practice Address - Street 2:SUITE 956
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-5000
Practice Address - Country:US
Practice Address - Phone:618-233-3273
Practice Address - Fax:618-234-7233
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2017-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0086831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical