Provider Demographics
NPI:1609987395
Name:FENNA, CARLA JO (OTRL)
Entity type:Individual
Prefix:MS
First Name:CARLA
Middle Name:JO
Last Name:FENNA
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 JAYDE PLACE
Mailing Address - Street 2:
Mailing Address - City:POPLAR GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:61065-8314
Mailing Address - Country:US
Mailing Address - Phone:815-765-2715
Mailing Address - Fax:815-765-2715
Practice Address - Street 1:402 JAYDE PLACE
Practice Address - Street 2:
Practice Address - City:POPLAR GROVE
Practice Address - State:IL
Practice Address - Zip Code:61065-8314
Practice Address - Country:US
Practice Address - Phone:815-765-2715
Practice Address - Fax:815-765-2715
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCF02520398POtherEARLY INTERVENTION