Provider Demographics
NPI:1710491170
Name:CARLSON, TERA L (CCC,SLP/L)
Entity Type:Individual
Prefix:MRS
First Name:TERA
Middle Name:L
Last Name:CARLSON
Suffix:
Gender:F
Credentials:CCC,SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11301 EXETER DR
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-8648
Mailing Address - Country:US
Mailing Address - Phone:708-253-5765
Mailing Address - Fax:
Practice Address - Street 1:15100 S 94TH AVE
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-3291
Practice Address - Country:US
Practice Address - Phone:708-364-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146004985235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist