Provider Demographics
NPI:1649949033
Name:FUSSNER, KARSEN ELAINE (COTA/L)
Entity type:Individual
Prefix:
First Name:KARSEN
Middle Name:ELAINE
Last Name:FUSSNER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4717 N KNOXVILLE AVE APT 324
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-6137
Mailing Address - Country:US
Mailing Address - Phone:309-712-6211
Mailing Address - Fax:
Practice Address - Street 1:2220 STATE ST
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-3937
Practice Address - Country:US
Practice Address - Phone:309-347-1110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.005628224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant