Healthcare Provider Details

I. General information

NPI: 1972922912
Provider Name (Legal Business Name): MARISA MEJIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2014
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 CABOT DR
LISLE IL
60532-3607
US

IV. Provider business mailing address

2500 CABOT DR
LISLE IL
60532-3607
US

V. Phone/Fax

Practice location:
  • Phone: 630-864-3800
  • Fax:
Mailing address:
  • Phone: 630-864-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056.010362
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: