Provider Demographics
NPI:1568961670
Name:CALDERON, LISSETTE
Entity Type:Individual
Prefix:
First Name:LISSETTE
Middle Name:
Last Name:CALDERON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1279 ORIOLE TRL
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188-6063
Mailing Address - Country:US
Mailing Address - Phone:773-318-2348
Mailing Address - Fax:
Practice Address - Street 1:2233 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-8151
Practice Address - Country:US
Practice Address - Phone:773-318-2348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-03
Last Update Date:2018-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL56005540225X00000X
IL056005540225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist