MEDICARE: MS. JOANNE CARBONELL-RODRIGUEZ DT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Q00000X	Developmental Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	JC54880398P	OTHER	IL	EARLY INTERVENTION PROVID

General Provider Information

NPI Number	:	1508909797
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JOANNE CARBONELL-RODRIGUEZ DT

Provider Business Mailing Address
First Line	:	2800 W JEROME ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60645-1231
Country	:	US
Telephone Number	:	773-508-0329
Fax Number	:	773-274-8685

Provider Business Practice Location Address
First Line	:	3040 N WILTON AVE
Second Line	:	2ND FL
City	:	CHICAGO
State	:	IL
Zip	:	60657-4424
Country	:	US
Telephone Number	:	773-296-7687
Fax Number	:	773-296-7281

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/15/2007
Last Update Date	:	07/08/2007

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Directions to “ MS. JOANNE CARBONELL-RODRIGUEZ DT” Practice Location

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