Provider Demographics
NPI:1407471634
Name:MACIAS, MIANIE JARO (PT)
Entity Type:Individual
Prefix:
First Name:MIANIE
Middle Name:JARO
Last Name:MACIAS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 LEXINGTON LN
Mailing Address - Street 2:
Mailing Address - City:ROLLING MEADOWS
Mailing Address - State:IL
Mailing Address - Zip Code:60008-2104
Mailing Address - Country:US
Mailing Address - Phone:312-810-6557
Mailing Address - Fax:
Practice Address - Street 1:275 E ARMY TRAIL RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-2135
Practice Address - Country:US
Practice Address - Phone:630-893-9616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070019561225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist