MEDICARE: ANDREA LAUREN CARLSON OTD, OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	056.014936	IL

General Provider Information

NPI Number	:	1013643238
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA LAUREN CARLSON OTD, OTR/L

Provider Business Mailing Address
First Line	:	2539 N SAWYER AVE APT A
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-1430
Country	:	US
Telephone Number	:	815-708-3538
Fax Number	:

Provider Business Practice Location Address
First Line	:	1607 W HOWARD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-1675
Country	:	US
Telephone Number	:	312-952-8993
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2022
Last Update Date	:	07/25/2023

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