Healthcare Provider Details

I. General information

NPI: 1245322759
Provider Name (Legal Business Name): RENEE L CARLSON DT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 S GOSSE BLVD
PRINCETON IL
61356-1916
US

IV. Provider business mailing address

406 S GOSSE BLVD
PRINCETON IL
61356-1916
US

V. Phone/Fax

Practice location:
  • Phone: 815-875-4548
  • Fax: 815-875-8602
Mailing address:
  • Phone: 815-875-4548
  • Fax: 815-875-8602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License NumberRC11700805P
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: