Provider Demographics
NPI:1790150340
Name:YARAK, MARY KAY
Entity Type:Individual
Prefix:
First Name:MARY KAY
Middle Name:
Last Name:YARAK
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 1:1537 N WASHTENAW AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1636
Mailing Address - Country:US
Mailing Address - Phone:773-252-8684
Mailing Address - Fax:
Practice Address - Street 1:1537 N WASHTENAW AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1636
Practice Address - Country:US
Practice Address - Phone:773-252-8684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.003810320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities