Provider Demographics
NPI:1740599489
Name:PRENDERGAST, MICHAJA LYNN
Entity Type:Individual
Prefix:
First Name:MICHAJA
Middle Name:LYNN
Last Name:PRENDERGAST
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 1:2600 N HAMPDEN CT
Mailing Address - Street 2:K7
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-4943
Mailing Address - Country:US
Mailing Address - Phone:810-656-2863
Mailing Address - Fax:
Practice Address - Street 1:1820 W WEBSTER AVE
Practice Address - Street 2:2
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2934
Practice Address - Country:US
Practice Address - Phone:810-656-2863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-29
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.008197225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist