Provider Demographics
NPI:1477704500
Name:KOSCIANIUK, MARY ANNE (OT)
Entity Type:Individual
Prefix:
First Name:MARY ANNE
Middle Name:
Last Name:KOSCIANIUK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11411 W 183RD ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-9450
Mailing Address - Country:US
Mailing Address - Phone:708-478-1820
Mailing Address - Fax:708-478-3316
Practice Address - Street 1:11411 W 183RD ST
Practice Address - Street 2:SUITE B
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-9450
Practice Address - Country:US
Practice Address - Phone:708-478-1820
Practice Address - Fax:708-478-3316
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056006879225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist