Healthcare Provider Details

I. General information

NPI: 1700161288
Provider Name (Legal Business Name): MELISSA ANN VAZQUEZ LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6731 N ROCKWELL ST
CHICAGO IL
60645-4625
US

IV. Provider business mailing address

6731 N ROCKWELL STREET
CHICAGO IL
60645
US

V. Phone/Fax

Practice location:
  • Phone: 773-355-8889
  • Fax:
Mailing address:
  • Phone: 773-355-8889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160.007334
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227.010334
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: