Provider Demographics
NPI:1568098606
Name:MAMIS, EMMA KATE (R-DMT)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:KATE
Last Name:MAMIS
Suffix:
Gender:F
Credentials:R-DMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4350 N BROADWAY ST STE 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-6043
Mailing Address - Country:US
Mailing Address - Phone:773-883-4663
Mailing Address - Fax:
Practice Address - Street 1:4350 N BROADWAY ST STE 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-6043
Practice Address - Country:US
Practice Address - Phone:773-883-4663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-20
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
R-DMT-2515225600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist