Provider Demographics
NPI:1619414521
Name:VACI, MIA (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:VACI
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6116 S MASSASOIT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16W361 S FRONTAGE RD
Practice Address - Street 2:SUITE 131
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-5830
Practice Address - Country:US
Practice Address - Phone:630-590-5571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-30
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056011815225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist