Healthcare Provider Details

I. General information

NPI: 1578043121
Provider Name (Legal Business Name): AVA MARVIN MT-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2018
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 LAKE STREET SUITE 100C
OAK PARK IL
60301
US

IV. Provider business mailing address

1100 LAKE ST STE 100C
OAK PARK IL
60301-1028
US

V. Phone/Fax

Practice location:
  • Phone: 708-620-2373
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number13846
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: