Provider Demographics
NPI:1679348163
Name:CHRISTIANSON, MAE ELISE (OTR/L)
Entity Type:Individual
Prefix:
First Name:MAE
Middle Name:ELISE
Last Name:CHRISTIANSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5438 N BERNARD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-4614
Mailing Address - Country:US
Mailing Address - Phone:773-251-0120
Mailing Address - Fax:
Practice Address - Street 1:5669 N NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-6153
Practice Address - Country:US
Practice Address - Phone:773-467-5669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.015684225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist