Provider Demographics
NPI:1053535203
Name:EVENHOUSE, CAROL S (CDS CHILD DEVELOPMEN)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:S
Last Name:EVENHOUSE
Suffix:
Gender:F
Credentials:CDS CHILD DEVELOPMEN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 S OLD MILL LANE
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527
Mailing Address - Country:US
Mailing Address - Phone:630-323-2398
Mailing Address - Fax:630-323-2390
Practice Address - Street 1:35 S OLD MILL LANE
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527
Practice Address - Country:US
Practice Address - Phone:630-323-2398
Practice Address - Fax:630-323-2390
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILCE96020698P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1000444156276201Medicaid