MEDICARE: MARISOL PEREZ

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	235Z00000X	Speech-Language Pathologist		IL

General Provider Information

NPI Number	:	1780154070
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISOL PEREZ

Provider Business Mailing Address
First Line	:	3043 N KOLMAR AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-5217
Country	:	US
Telephone Number	:	773-663-2871
Fax Number	:

Provider Business Practice Location Address
First Line	:	3043 N KOLMAR AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-5217
Country	:	US
Telephone Number	:	773-663-2871
Fax Number	:

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

Provider Enumeration Date	:	11/29/2018
Last Update Date	:	11/29/2018

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Directions to “ MARISOL PEREZ ” Practice Location

Language	Start Address	Practice Location

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