Provider Demographics
NPI:1932990645
Name:CARLSON, NICOLE GRACE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:GRACE
Last Name:CARLSON
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:PO BOX 735263
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5263
Mailing Address - Country:US
Mailing Address - Phone:877-632-6637
Mailing Address - Fax:708-409-5179
Practice Address - Street 1:2011 YORK RD
Practice Address - Street 2:
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-1992
Practice Address - Country:US
Practice Address - Phone:580-470-8740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-13
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056016697225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist