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NPI Code Detail

MEDICARE: CARLY NICOLE DECKER OT

MEDICARE: CARLY NICOLE DECKER OT
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
1225X00000XOccupational Therapist99049402AIN
2225X00000XOccupational Therapist056.009784IL

General Provider Information

NPI Number : 1750651659
Entity Type Code : Individual
Provider Name (Legal Business Name) : CARLY NICOLE DECKER OT
Provider Business Mailing Address
First Line : 929 W FOSTER AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60640-1491
Country : US
Telephone Number : 812-236-9501
Fax Number :
Provider Business Practice Location Address
First Line : 929 W FOSTER AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60640-1491
Country : US
Telephone Number : 812-236-9501
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/09/2012
Last Update Date : 03/28/2014

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Directions to “ CARLY NICOLE DECKER OT” Practice Location

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