Provider Demographics
NPI:1356858310
Name:ROESCHLEY, CARLEN ANNE (EDS)
Entity Type:Individual
Prefix:MS
First Name:CARLEN
Middle Name:ANNE
Last Name:ROESCHLEY
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:CARLEN
Other - Middle Name:ROESCHLEY
Other - Last Name:OWENS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:EDS
Mailing Address - Street 1:1050 S 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-2526
Mailing Address - Country:US
Mailing Address - Phone:309-263-0522
Mailing Address - Fax:309-284-8015
Practice Address - Street 1:1050 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-2526
Practice Address - Country:US
Practice Address - Phone:309-263-0522
Practice Address - Fax:309-284-8015
Is Sole Proprietor?:No
Enumeration Date:2017-12-29
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1847773103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool