Healthcare Provider Details

I. General information

NPI: 1609126374
Provider Name (Legal Business Name): MONICA MARIE CARLSON MOTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2012
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2122 TROY RD
EDWARDSVILLE IL
62025-2540
US

IV. Provider business mailing address

2122 TROY RD
EDWARDSVILLE IL
62025-2540
US

V. Phone/Fax

Practice location:
  • Phone: 618-800-4620
  • Fax:
Mailing address:
  • Phone: 618-363-6728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056.009830
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: