Provider Demographics
NPI:1578045696
Name:COLVIN, CARLEEN
Entity Type:Individual
Prefix:
First Name:CARLEEN
Middle Name:
Last Name:COLVIN
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 1:29788 E PHILLIPS RD
Mailing Address - Street 2:
Mailing Address - City:GLASFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61533-9441
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29788 E PHILLIPS RD
Practice Address - Street 2:
Practice Address - City:GLASFORD
Practice Address - State:IL
Practice Address - Zip Code:61533-9441
Practice Address - Country:US
Practice Address - Phone:309-303-7233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist