Provider Demographics
NPI:1225400013
Name:MAC, DOROTHY
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:
Last Name:MAC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 S RIVERSIDE PLZ
Mailing Address - Street 2:830
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-5808
Mailing Address - Country:US
Mailing Address - Phone:312-416-3804
Mailing Address - Fax:
Practice Address - Street 1:222 S RIVERSIDE PLZ
Practice Address - Street 2:830
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606-5808
Practice Address - Country:US
Practice Address - Phone:312-416-3804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160004843225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant