Provider Demographics
NPI:1548400179
Name:MARCELLO, MARK (LMT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MARCELLO
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 OLD FARM LN
Mailing Address - Street 2:
Mailing Address - City:CARPENTERSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60110-1461
Mailing Address - Country:US
Mailing Address - Phone:847-224-5108
Mailing Address - Fax:
Practice Address - Street 1:143 OLD FARM LN
Practice Address - Street 2:
Practice Address - City:CARPENTERSVILLE
Practice Address - State:IL
Practice Address - Zip Code:60110-1461
Practice Address - Country:US
Practice Address - Phone:847-224-5108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-22
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.009599225700000X
IL057.001111224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist