Provider Demographics
NPI:1104210533
Name:CARSON, ARTHUR DUPREE (COTA/L)
Entity Type:Individual
Prefix:
First Name:ARTHUR
Middle Name:DUPREE
Last Name:CARSON
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7653 S BISHOP ST APT 1S
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620-4126
Mailing Address - Country:US
Mailing Address - Phone:773-723-6180
Mailing Address - Fax:
Practice Address - Street 1:3703 W LAKE AVE STE 200
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-1266
Practice Address - Country:US
Practice Address - Phone:847-998-1188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-24
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.000457311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home