Provider Demographics
NPI:1467070102
Name:MACIAS, EMILY CAROLINE (COTA/L)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:CAROLINE
Last Name:MACIAS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4622 VALLEYDALE RD
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035-4715
Mailing Address - Country:US
Mailing Address - Phone:618-600-3391
Mailing Address - Fax:
Practice Address - Street 1:1373 DADRIAN PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-1767
Practice Address - Country:US
Practice Address - Phone:618-467-7062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.005398224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant