Provider Demographics
NPI:1629323696
Name:VISCONDE, MARIEL DE VERA (RPT)
Entity Type:Individual
Prefix:
First Name:MARIEL
Middle Name:DE VERA
Last Name:VISCONDE
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E IRVING PARK RD
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:IL
Mailing Address - Zip Code:60172-2048
Mailing Address - Country:US
Mailing Address - Phone:630-439-0009
Mailing Address - Fax:630-439-0011
Practice Address - Street 1:3115 LEWIS AVE
Practice Address - Street 2:
Practice Address - City:ZION
Practice Address - State:IL
Practice Address - Zip Code:60099-3099
Practice Address - Country:US
Practice Address - Phone:847-746-3752
Practice Address - Fax:847-746-9144
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-16
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070018847225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400167510Medicare PIN
ILF400167423Medicare PIN