Provider Demographics
NPI:1578043121
Name:MARVIN, AVA (MT-BC)
Entity Type:Individual
Prefix:
First Name:AVA
Middle Name:
Last Name:MARVIN
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 LAKE ST STE 100C
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1028
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 LAKE STREET
Practice Address - Street 2:SUITE 100C
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301
Practice Address - Country:US
Practice Address - Phone:708-620-2373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL13846225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist