Provider Demographics
NPI:1215308192
Name:DAHLQUIST, CAREY
Entity type:Individual
Prefix:
First Name:CAREY
Middle Name:
Last Name:DAHLQUIST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 FRANK SCOTT PKWY W
Mailing Address - Street 2:SUITE 824
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-5007
Mailing Address - Country:US
Mailing Address - Phone:618-234-9705
Mailing Address - Fax:618-257-0665
Practice Address - Street 1:2338 W VAN WINKLE WAY
Practice Address - Street 2:SUITE 3100
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-7483
Practice Address - Country:US
Practice Address - Phone:309-693-9189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-16
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070021581225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist