Basic Information
| Provider Information | |||||||||
| NPI: | 1912139593 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARNAHAN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | MARGARET | ||||||||
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| Credential: | LPE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1440 SAINT JOHNS CHURCH RD NE | ||||||||
| Address2: | |||||||||
| City: | LANESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471368536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5015388274 | ||||||||
| FaxNumber: | 7088455505 | ||||||||
| Practice Location | |||||||||
| Address1: | 7485 STATE ROAD 64 | ||||||||
| Address2: | |||||||||
| City: | GEORGETOWN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471228735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5015388274 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2009 | ||||||||
| LastUpdateDate: | 04/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 11-01EI | AR | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 180.009927 | IL | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 39003461A | IN | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 116399726 | 05 | AR | MEDICAID |