Provider Demographics
NPI:1013277912
Name:AGUILA CARSON, MARY JANE A (PT)
Entity Type:Individual
Prefix:
First Name:MARY JANE
Middle Name:A
Last Name:AGUILA CARSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1639 CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-6636
Mailing Address - Country:US
Mailing Address - Phone:708-357-3249
Mailing Address - Fax:
Practice Address - Street 1:1639 CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-6636
Practice Address - Country:US
Practice Address - Phone:708-357-3249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-24
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070014588225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist