Provider Demographics
NPI:1831251073
Name:CARRENO, BETTY (PT)
Entity type:Individual
Prefix:
First Name:BETTY
Middle Name:
Last Name:CARRENO
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 1:6039 N MOZART
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659
Mailing Address - Country:US
Mailing Address - Phone:773-316-5305
Mailing Address - Fax:773-743-4881
Practice Address - Street 1:1505 W DEVON
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660
Practice Address - Country:US
Practice Address - Phone:773-316-5305
Practice Address - Fax:773-743-4881
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070010042225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL300084121OtherTAX ID
IL1285635532OtherORGANIZATION NPI
ILK08699Medicare PIN