Healthcare Provider Details

I. General information

NPI: 1033658356
Provider Name (Legal Business Name): MARYROSE GUEVARA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2017
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5793 N LINCOLN AVE
CHICAGO IL
60659-4722
US

IV. Provider business mailing address

4902 N SEELEY AVE APT 2
CHICAGO IL
60625-1314
US

V. Phone/Fax

Practice location:
  • Phone: 773-561-6370
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number070.021996
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: