Provider Demographics
NPI:1962063354
Name:DECKARD, CONNIE (MA)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:DECKARD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 516
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62439
Mailing Address - Country:US
Mailing Address - Phone:618-943-3302
Mailing Address - Fax:618-943-7589
Practice Address - Street 1:LAWRENCE COUNTY HEALTH DEPARTMENT BEHAVIOR HEALTH
Practice Address - Street 2:11020 STATE ROUTE 250
Practice Address - City:LAWRENCEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62439
Practice Address - Country:US
Practice Address - Phone:618-943-3754
Practice Address - Fax:618-943-3657
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3760061789008Medicaid