Provider Demographics
NPI:1669680898
Name:WHITE, MARY ELIZABETH (OTR)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:WHITE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:BETSEY
Other - Middle Name:
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR
Mailing Address - Street 1:1061 W 16TH ST
Mailing Address - Street 2:UNIT 109
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-2205
Mailing Address - Country:US
Mailing Address - Phone:312-403-1209
Mailing Address - Fax:
Practice Address - Street 1:2835 N SHEFFIELD AVE
Practice Address - Street 2:SUITE 401
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5081
Practice Address - Country:US
Practice Address - Phone:773-883-2190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.00580225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics