Healthcare Provider Details

I. General information

NPI: 1467388710
Provider Name (Legal Business Name): MARY KOTJABALDIRI APN-PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7765 LAKE ST APT 2W
RIVER FOREST IL
60305-1732
US

IV. Provider business mailing address

7765 LAKE ST APT 2W
RIVER FOREST IL
60305-1732
US

V. Phone/Fax

Practice location:
  • Phone: 708-955-6144
  • Fax:
Mailing address:
  • Phone: 708-955-6144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209035881
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: