Provider Demographics
NPI:1609038249
Name:MULYE, MANEESHA D (OT)
Entity Type:Individual
Prefix:
First Name:MANEESHA
Middle Name:D
Last Name:MULYE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1223 BIRCHDALE LN
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-6553
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1219 W ROOSEVELT RD
Practice Address - Street 2:SUITE C
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-4046
Practice Address - Country:US
Practice Address - Phone:708-216-5300
Practice Address - Fax:708-531-7936
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-006885225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK53273Medicare PIN