Provider Demographics
NPI:1275198665
Name:CARLSON, BRIANNA (COTA)
Entity Type:Individual
Prefix:MRS
First Name:BRIANNA
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MS
Other - First Name:BRIANNA
Other - Middle Name:
Other - Last Name:BLEICHNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:1131 N JACQUALINE LN
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356-8229
Mailing Address - Country:US
Mailing Address - Phone:309-258-0515
Mailing Address - Fax:
Practice Address - Street 1:1131 N JACQUALINE LN
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356-8229
Practice Address - Country:US
Practice Address - Phone:309-258-0515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-01
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.004309224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant