Provider Demographics
NPI:1124468830
Name:MUMMA, CARSON (OTR/L)
Entity type:Individual
Prefix:
First Name:CARSON
Middle Name:
Last Name:MUMMA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2119 W BELMONT AVE
Mailing Address - Street 2:1C
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-6463
Mailing Address - Country:US
Mailing Address - Phone:717-572-5899
Mailing Address - Fax:
Practice Address - Street 1:2119 W BELMONT AVE
Practice Address - Street 2:1C
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-6463
Practice Address - Country:US
Practice Address - Phone:717-572-5899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.009831225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist