Provider Demographics
NPI:1245322759
Name:CARLSON, RENEE L (DT)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:L
Last Name:CARLSON
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 S GOSSE BLVD
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356-1916
Mailing Address - Country:US
Mailing Address - Phone:815-875-4548
Mailing Address - Fax:815-875-8602
Practice Address - Street 1:406 S GOSSE BLVD
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356-1916
Practice Address - Country:US
Practice Address - Phone:815-875-4548
Practice Address - Fax:815-875-8602
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRC11700805P2080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics