Healthcare Provider Details

I. General information

NPI: 1871140806
Provider Name (Legal Business Name): MARY K MIXAN DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2019
Last Update Date: 10/24/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3922 N SHERIDAN RD
CHICAGO IL
60613-2926
US

IV. Provider business mailing address

600 OAKMONT LN STE 600C
WESTMONT IL
60559-5548
US

V. Phone/Fax

Practice location:
  • Phone: 773-327-0040
  • Fax: 773-327-0040
Mailing address:
  • Phone: 630-575-1980
  • Fax: 630-928-5080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070-024795
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: