Basic Information
| Provider Information | |||||||||
| NPI: | 1649949033 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FUSSNER | ||||||||
| FirstName: | KARSEN | ||||||||
| MiddleName: | ELAINE | ||||||||
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| Credential: | COTA/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4717 N KNOXVILLE AVE APT 324 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616146137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097126211 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2220 STATE ST | ||||||||
| Address2: | |||||||||
| City: | PEKIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615543937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3093471110 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2021 | ||||||||
| LastUpdateDate: | 09/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 057.005628 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.