Provider Demographics
NPI:1154696300
Name:WILLINGHAM, CARL L (HIS)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:L
Last Name:WILLINGHAM
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2757 S CLARK ST STE B
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-3812
Mailing Address - Country:US
Mailing Address - Phone:573-581-6633
Mailing Address - Fax:573-581-9998
Practice Address - Street 1:2757 S CLARK ST STE B
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-3812
Practice Address - Country:US
Practice Address - Phone:573-581-6633
Practice Address - Fax:573-581-9998
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-20
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001025782237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist