Provider Demographics
NPI:1174970537
Name:PISTER, CARLA L
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:L
Last Name:PISTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:L
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:8322 FROST CT
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-4504
Mailing Address - Country:US
Mailing Address - Phone:630-379-6519
Mailing Address - Fax:
Practice Address - Street 1:8322 FROST CT
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-4504
Practice Address - Country:US
Practice Address - Phone:630-379-6519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-16
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-004945225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid