Provider Demographics
NPI:1386949196
Name:CARSON, TERESA LOUISE
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:LOUISE
Last Name:CARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:
Other - Last Name:SHARPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2122 YORK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1925
Mailing Address - Country:US
Mailing Address - Phone:570-550-0168
Mailing Address - Fax:410-648-4878
Practice Address - Street 1:317 NORTH BLVD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-1911
Practice Address - Country:US
Practice Address - Phone:910-249-4040
Practice Address - Fax:910-249-9250
Is Sole Proprietor?:No
Enumeration Date:2011-01-26
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP22318225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR188912721Medicaid
AR188912721Medicaid