Healthcare Provider Details

I. General information

NPI: 1659072387
Provider Name (Legal Business Name): MACIEL ROA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2023
Last Update Date: 07/11/2026
Certification Date: 07/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7423 MADISON ST
FOREST PARK IL
60130-1502
US

IV. Provider business mailing address

2535 GUNDERSON AVE
BERWYN IL
60402-2645
US

V. Phone/Fax

Practice location:
  • Phone: 708-435-4130
  • Fax:
Mailing address:
  • Phone: 773-574-1106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number242.018634
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: