Healthcare Provider Details

I. General information

NPI: 1194294413
Provider Name (Legal Business Name): MARGO ROETHLISBERGER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2018
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 W 177TH ST STE 1F
HAZEL CREST IL
60429-2186
US

IV. Provider business mailing address

98 CHELSEA AVE
SUGAR GROVE IL
60554-5407
US

V. Phone/Fax

Practice location:
  • Phone: 708-745-3040
  • Fax:
Mailing address:
  • Phone: 217-737-2962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180002364
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: