Provider Demographics
NPI:1215246129
Name:PERSLEY, CAROL J (LCSW)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:J
Last Name:PERSLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:J
Other - Last Name:RAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:550 S ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2165
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 S ADAMS ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403
Practice Address - Country:US
Practice Address - Phone:812-333-6324
Practice Address - Fax:812-331-6700
Is Sole Proprietor?:No
Enumeration Date:2010-09-28
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34006087A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
M400028639Medicare PIN