Provider Demographics
NPI:1801919022
Name:BOUC, CARLA EVONNE (LCPC)
Entity type:Individual
Prefix:MRS
First Name:CARLA
Middle Name:EVONNE
Last Name:BOUC
Suffix:
Gender:
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 S VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-3689
Mailing Address - Country:US
Mailing Address - Phone:618-236-2482
Mailing Address - Fax:
Practice Address - Street 1:812 S VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-3689
Practice Address - Country:US
Practice Address - Phone:618-236-2482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
IL180013435101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist