Provider Demographics
NPI:1578750386
Name:ROSZELL, RICHARD RAY (LMT)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:RAY
Last Name:ROSZELL
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 1:4249 N FRANCISCO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-2609
Mailing Address - Country:US
Mailing Address - Phone:773-895-0574
Mailing Address - Fax:
Practice Address - Street 1:1111 WESTGATE ST
Practice Address - Street 2:#115
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1007
Practice Address - Country:US
Practice Address - Phone:773-895-0574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-26
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist