Provider Demographics
NPI:1851082804
Name:CARBONE, KATHLEEN ANN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANN
Last Name:CARBONE
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 1:1720 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CREST HILL
Mailing Address - State:IL
Mailing Address - Zip Code:60403-1928
Mailing Address - Country:US
Mailing Address - Phone:815-685-6934
Mailing Address - Fax:
Practice Address - Street 1:1720 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CREST HILL
Practice Address - State:IL
Practice Address - Zip Code:60403-1928
Practice Address - Country:US
Practice Address - Phone:815-685-6934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227017783225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist