Healthcare Provider Details

I. General information

NPI: 1013335637
Provider Name (Legal Business Name): KELLY CARRERA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2014
Last Update Date: 10/05/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 W FULLERTON AVE
CHICAGO IL
60614-2129
US

IV. Provider business mailing address

1320 W FULLERTON AVE
CHICAGO IL
60614-2129
US

V. Phone/Fax

Practice location:
  • Phone: 773-770-2419
  • Fax:
Mailing address:
  • Phone: 773-770-2419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number070020671
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: