Healthcare Provider Details

I. General information

NPI: 1508909797
Provider Name (Legal Business Name): JOANNE CARBONELL-RODRIGUEZ DT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3040 N WILTON AVE 2ND FL
CHICAGO IL
60657-4424
US

IV. Provider business mailing address

2800 W JEROME ST
CHICAGO IL
60645-1231
US

V. Phone/Fax

Practice location:
  • Phone: 773-296-7687
  • Fax: 773-296-7281
Mailing address:
  • Phone: 773-508-0329
  • Fax: 773-274-8685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: