Healthcare Provider Details

I. General information

NPI: 1598121725
Provider Name (Legal Business Name): CARSON MOESLE ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2016
Last Update Date: 09/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8548 GOLFVIEW DR
ORLAND PARK IL
60462-2851
US

IV. Provider business mailing address

8548 GOLFVIEW DR
ORLAND PARK IL
60462-2851
US

V. Phone/Fax

Practice location:
  • Phone: 708-606-3760
  • Fax:
Mailing address:
  • Phone: 708-606-3760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070024015
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberM24011592870
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: