Provider Demographics
NPI:1437428166
Name:FARRELL, AUDREY (LMT)
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:
Last Name:FARRELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1931 W EVERGREEN AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-6958
Mailing Address - Country:US
Mailing Address - Phone:312-802-0493
Mailing Address - Fax:773-227-9160
Practice Address - Street 1:1834 W NORTH AVE # 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1312
Practice Address - Country:US
Practice Address - Phone:773-227-9150
Practice Address - Fax:773-227-9160
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-27
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.013694225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist