Provider Demographics
NPI:1144965997
Name:INTERIAL, CARLEY MARIE
Entity type:Individual
Prefix:
First Name:CARLEY
Middle Name:MARIE
Last Name:INTERIAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 S MICHIGAN AVE STE 900
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60604-4393
Mailing Address - Country:US
Mailing Address - Phone:855-832-6727
Mailing Address - Fax:772-675-9100
Practice Address - Street 1:332 S MICHIGAN AVE STE 900
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604-4393
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:772-675-9100
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-04
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-23-64068103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst