MEDICARE: RAEESA MAHMOOD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant

General Provider Information

NPI Number	:	1366001067
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAEESA MAHMOOD

Provider Business Mailing Address
First Line	:	3913 TULIP ST
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-2329
Country	:	US
Telephone Number	:	773-603-8542
Fax Number	:

Provider Business Practice Location Address
First Line	:	3913 TULIP ST
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-2329
Country	:	US
Telephone Number	:	773-603-8542
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2019
Last Update Date	:	06/07/2019

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Directions to “ RAEESA MAHMOOD ” Practice Location

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