Provider Demographics
NPI:1467020230
Name:BISCONTINE, CARLEEN MARIE
Entity Type:Individual
Prefix:
First Name:CARLEEN
Middle Name:MARIE
Last Name:BISCONTINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 AUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-9315
Mailing Address - Country:US
Mailing Address - Phone:309-657-6209
Mailing Address - Fax:
Practice Address - Street 1:1401 AUSTIN AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IL
Practice Address - Zip Code:61571-9315
Practice Address - Country:US
Practice Address - Phone:309-657-6209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057005044224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant