Healthcare Provider Details

I. General information

NPI: 1033161252
Provider Name (Legal Business Name): ESTHERLYN MAYMON MPA, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 06/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 S DAMEN AVE PM&R #117
CHICAGO IL
60612-3728
US

IV. Provider business mailing address

820 S DAMEN AVE PMR#117
CHICAGO IL
60612-3728
US

V. Phone/Fax

Practice location:
  • Phone: 312-569-7956
  • Fax: 312-569-7956
Mailing address:
  • Phone: 312-569-7956
  • Fax: 312-569-8050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number056001169
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: