Provider Demographics
NPI:1790339091
Name:SIMON, MARICELA (LAC)
Entity Type:Individual
Prefix:
First Name:MARICELA
Middle Name:
Last Name:SIMON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 HARVEST DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-1891
Mailing Address - Country:US
Mailing Address - Phone:773-208-7187
Mailing Address - Fax:
Practice Address - Street 1:2504 WASHINGTON ST STE 205-E
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-4960
Practice Address - Country:US
Practice Address - Phone:773-208-7187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist