Provider Demographics
NPI:1073795845
Name:RAKIDZIOSKI, MARYANNE (MOT)
Entity Type:Individual
Prefix:MISS
First Name:MARYANNE
Middle Name:
Last Name:RAKIDZIOSKI
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1328 CARRIAGE LANE
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:N9H1Z9
Mailing Address - Country:CA
Mailing Address - Phone:773-595-6277
Mailing Address - Fax:
Practice Address - Street 1:5103 W JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644
Practice Address - Country:US
Practice Address - Phone:773-595-6277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT9687225X00000X
MI5201007169225X00000X
IL056.008476225X00000X
FL12818225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1073795845Medicaid