Provider Demographics
NPI:1720264195
Name:CARMODY, MS, LPC, LINDA A
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:A
Last Name:CARMODY, MS, LPC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:A
Other - Last Name:NEVILLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, LPC
Mailing Address - Street 1:1496 BELLEVUE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-4205
Mailing Address - Country:US
Mailing Address - Phone:920-784-2644
Mailing Address - Fax:920-784-2655
Practice Address - Street 1:1496 BELLEVUE ST STE 101
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-4205
Practice Address - Country:US
Practice Address - Phone:920-784-2644
Practice Address - Fax:920-784-2655
Is Sole Proprietor?:No
Enumeration Date:2008-01-16
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI101YM0800X
WI4151-125104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43729600Medicaid