Provider Demographics
NPI:1750354254
Name:SPITALLI, CARRIE LYNN (PSYD)
Entity type:Individual
Prefix:DR
First Name:CARRIE
Middle Name:LYNN
Last Name:SPITALLI
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 MOONEY DR STE 1
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-2172
Mailing Address - Country:US
Mailing Address - Phone:815-933-7887
Mailing Address - Fax:815-933-7870
Practice Address - Street 1:110 MOONEY DR
Practice Address - Street 2:SUITE 1
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2171
Practice Address - Country:US
Practice Address - Phone:815-933-7887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-005739103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical