Provider Demographics
NPI:1699792481
Name:TILLACK, CAROLYN (LCSW)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:TILLACK
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 1:57 S PRAIRIE ST
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:IL
Mailing Address - Zip Code:60013-2614
Mailing Address - Country:US
Mailing Address - Phone:847-507-3352
Mailing Address - Fax:
Practice Address - Street 1:317 W COLFAX ST
Practice Address - Street 2:SUITE 111
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60067-2535
Practice Address - Country:US
Practice Address - Phone:847-507-3352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0016301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149-001630OtherLIC.CLINICAL SOC. WKR.
IL0162-6486OtherBC/BS PROVIDER #
IL115 392 13OtherCAQH
IL115 392 13OtherCAQH