MEDICARE: MS. CARLA JO FENNA OTRL

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		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CF02520398P	OTHER	IL	EARLY INTERVENTION

General Provider Information

NPI Number	:	1609987395
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CARLA JO FENNA OTRL

Provider Business Mailing Address
First Line	:	402 JAYDE PLACE
Second Line	:
City	:	POPLAR GROVE
State	:	IL
Zip	:	61065-8314
Country	:	US
Telephone Number	:	815-765-2715
Fax Number	:	815-765-2715

Provider Business Practice Location Address
First Line	:	402 JAYDE PLACE
Second Line	:
City	:	POPLAR GROVE
State	:	IL
Zip	:	61065-8314
Country	:	US
Telephone Number	:	815-765-2715
Fax Number	:	815-765-2715

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	07/08/2007

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