Provider Demographics
NPI:1164477626
Name:PESAVENTO, MARI JO
Entity Type:Individual
Prefix:MRS
First Name:MARI
Middle Name:JO
Last Name:PESAVENTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARI
Other - Middle Name:JO
Other - Last Name:QUANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTPCS
Mailing Address - Street 1:3417 WEST 115TH PLACE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655
Mailing Address - Country:US
Mailing Address - Phone:773-445-8604
Mailing Address - Fax:773-239-9747
Practice Address - Street 1:3417 WEST 115TH PLACE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-3622
Practice Address - Country:US
Practice Address - Phone:773-445-8604
Practice Address - Fax:773-239-9747
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1683383Medicare UPIN
ILMP6271102999PMedicare UPIN