Provider Demographics
NPI:1588632350
Name:HAERTLING, CARRI A (PT)
Entity Type:Individual
Prefix:MRS
First Name:CARRI
Middle Name:A
Last Name:HAERTLING
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CARRI
Other - Middle Name:A
Other - Last Name:BRANDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:849 HARBOR WOODS DRIVE
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-3452
Mailing Address - Country:US
Mailing Address - Phone:618-830-6733
Mailing Address - Fax:
Practice Address - Street 1:206 W BROADWAY
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:IL
Practice Address - Zip Code:62293-1110
Practice Address - Country:US
Practice Address - Phone:618-224-9118
Practice Address - Fax:618-224-2129
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070011388225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070011388OtherPT
IL214314001Medicare UPIN
IL214314Medicare PIN