Healthcare Provider Details

I. General information

NPI: 1669599668
Provider Name (Legal Business Name): BRYAN J CARLSON M.S., OTR/L, CHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 09/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 N SHEFFIELD AVE
CHICAGO IL
60614-2215
US

IV. Provider business mailing address

625 ENTERPRISE DR
OAK BROOK IL
60523-8813
US

V. Phone/Fax

Practice location:
  • Phone: 773-281-7991
  • Fax:
Mailing address:
  • Phone: 630-575-6200
  • Fax: 630-928-5040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number056.006268
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056006268
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31005191A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: