Provider Demographics
NPI:1659480358
Name:NUTTER, CARRIE LYNN
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:LYNN
Last Name:NUTTER
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 1:1872 N CLYBOURN AVE APT 309
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-4916
Mailing Address - Country:US
Mailing Address - Phone:773-472-3834
Mailing Address - Fax:773-472-3753
Practice Address - Street 1:9416 SKOKIE BLVD
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077
Practice Address - Country:US
Practice Address - Phone:847-673-4800
Practice Address - Fax:847-673-9322
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
01632553OtherBC/BS
01632553OtherBC/BS