Provider Demographics
NPI:1639457294
Name:CHILSON, CARLENE L (MS)
Entity Type:Individual
Prefix:
First Name:CARLENE
Middle Name:L
Last Name:CHILSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:CARLIE
Other - Middle Name:L
Other - Last Name:CHILSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS
Mailing Address - Street 1:270 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:PENN YAN
Mailing Address - State:NY
Mailing Address - Zip Code:14527-1832
Mailing Address - Country:US
Mailing Address - Phone:315-536-2601
Mailing Address - Fax:315-536-1171
Practice Address - Street 1:270 LAKE ST
Practice Address - Street 2:
Practice Address - City:PENN YAN
Practice Address - State:NY
Practice Address - Zip Code:14527-1832
Practice Address - Country:US
Practice Address - Phone:315-536-2601
Practice Address - Fax:315-536-1171
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-01
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016738-1225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY225X00000XOtherOCCUAPTIONAL THERAPY