Provider Demographics
NPI:1508450305
Name:CORSO, CARLY ELIZABETH
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:ELIZABETH
Last Name:CORSO
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 1:16N919 GLEN OAKS CT
Mailing Address - Street 2:
Mailing Address - City:HAMPSHIRE
Mailing Address - State:IL
Mailing Address - Zip Code:60140-8991
Mailing Address - Country:US
Mailing Address - Phone:847-421-2774
Mailing Address - Fax:
Practice Address - Street 1:16N919 GLEN OAKS CT
Practice Address - Street 2:
Practice Address - City:HAMPSHIRE
Practice Address - State:IL
Practice Address - Zip Code:60140-8991
Practice Address - Country:US
Practice Address - Phone:847-421-2774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33008457A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker