Provider Demographics
NPI:1932634714
Name:CARLISLE, CARLY JEAN (MOT, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:JEAN
Last Name:CARLISLE
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 GABRIELLE CIR
Mailing Address - Street 2:
Mailing Address - City:BETHALTO
Mailing Address - State:IL
Mailing Address - Zip Code:62010-2594
Mailing Address - Country:US
Mailing Address - Phone:618-593-2909
Mailing Address - Fax:
Practice Address - Street 1:120 GABRIELLE CIR
Practice Address - Street 2:
Practice Address - City:BETHALTO
Practice Address - State:IL
Practice Address - Zip Code:62010-2594
Practice Address - Country:US
Practice Address - Phone:618-593-2909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-28
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056011096225X00000X
MO2015024426225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist