Basic Information
| Provider Information | |||||||||
| NPI: | 1386941524 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARSON | ||||||||
| FirstName: | RENEE | ||||||||
| MiddleName: | DIANE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21600 OXNARD ST | ||||||||
| Address2: | SUITE 1800 | ||||||||
| City: | WOODLAND HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913674976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183452345 | ||||||||
| FaxNumber: | 8184490994 | ||||||||
| Practice Location | |||||||||
| Address1: | 603 E DIEHL RD | ||||||||
| Address2: | SUITE 123 | ||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605631452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3318260226 | ||||||||
| FaxNumber: | 3313331864 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2011 | ||||||||
| LastUpdateDate: | 03/31/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | C62572485734 | IL | Y | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | 1-10-7382 | IL | N | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.