Provider Demographics
NPI:1841684123
Name:CARLTON, TINA (LAC)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:CARLTON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2138 W MCLEAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-4525
Mailing Address - Country:US
Mailing Address - Phone:773-317-9122
Mailing Address - Fax:
Practice Address - Street 1:6416 W HIGGINS AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60656-2203
Practice Address - Country:US
Practice Address - Phone:773-774-6771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-24
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198000558171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist