Provider Demographics
NPI:1851628143
Name:TEDESCHI, CARMEN MARIE (OTR/L)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:MARIE
Last Name:TEDESCHI
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:CARMEN
Other - Middle Name:MARIE
Other - Last Name:HICKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-1980
Mailing Address - Fax:630-928-5080
Practice Address - Street 1:1145 N HARLEM AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1529
Practice Address - Country:US
Practice Address - Phone:708-386-2086
Practice Address - Fax:708-386-3028
Is Sole Proprietor?:No
Enumeration Date:2009-11-09
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056008848225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00844083OtherMEDICARE RR
ILP00852542OtherMEDICARE RR
ILP00852542OtherMEDICARE RR
IL211585038Medicare PIN
IL209812005Medicare PIN
IL214692015Medicare PIN
IL206974008Medicare PIN
IL202845051Medicare PIN