Healthcare Provider Details

I. General information

NPI: 1356702955
Provider Name (Legal Business Name): MARISSA MARKHAM MOT, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2016
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 TYLER RD STE Q1
ST CHARLES IL
60174-3360
US

IV. Provider business mailing address

525 TYLER RD STE Q1
ST CHARLES IL
60174-3360
US

V. Phone/Fax

Practice location:
  • Phone: 630-444-0077
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number056.011428
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: