Healthcare Provider Details

I. General information

NPI: 1003685769
Provider Name (Legal Business Name): ASHLEY CARYN P SISON CEP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2023
Last Update Date: 12/22/2023
Certification Date: 12/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 W HARRISON ST
CHICAGO IL
60607-3106
US

IV. Provider business mailing address

805 S BISHOP ST APT 1R
CHICAGO IL
60607-4037
US

V. Phone/Fax

Practice location:
  • Phone: 312-563-2531
  • Fax:
Mailing address:
  • Phone: 773-848-8980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number1072790
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: