Provider Demographics
NPI:1194256990
Name:WORTHINGTON, CAROL ANN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:ANN
Last Name:WORTHINGTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 CYPRESS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-1947
Mailing Address - Country:US
Mailing Address - Phone:618-977-5108
Mailing Address - Fax:
Practice Address - Street 1:808 S MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-2499
Practice Address - Country:US
Practice Address - Phone:618-327-7130
Practice Address - Fax:888-690-4813
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150015239104100000X
IL1490206281041C0700X
IL149.0206281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370968305002Medicaid