Provider Demographics
NPI:1497762868
Name:CARLSON, CHERYL ANN (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:ANN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 MOORE AVE
Mailing Address - Street 2:
Mailing Address - City:LE ROY
Mailing Address - State:IL
Mailing Address - Zip Code:61752-1580
Mailing Address - Country:US
Mailing Address - Phone:309-212-1567
Mailing Address - Fax:309-962-6027
Practice Address - Street 1:305 MOORE AVE
Practice Address - Street 2:
Practice Address - City:LE ROY
Practice Address - State:IL
Practice Address - Zip Code:61752-1580
Practice Address - Country:US
Practice Address - Phone:309-212-1567
Practice Address - Fax:309-962-6027
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL00732086OtherBLUE CROSS BLUE SHIELD