Provider Demographics
NPI:1679847479
Name:BLAUSTEIN, MARA
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:BLAUSTEIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 W WRIGHTWOOD AVE
Mailing Address - Street 2:#4
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1250
Mailing Address - Country:US
Mailing Address - Phone:773-234-2225
Mailing Address - Fax:
Practice Address - Street 1:1201 W WRIGHTWOOD AVE
Practice Address - Street 2:#4
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1250
Practice Address - Country:US
Practice Address - Phone:773-234-2225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-27
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist