Provider Demographics
NPI:1790796985
Name:LANDRETH, MARY ANNE (OT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANNE
Last Name:LANDRETH
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:A
Other - Last Name:DYKSTRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:9645 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1722
Practice Address - Country:US
Practice Address - Phone:773-239-2734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2021-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-007516225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00796509OtherMEDICARE RR
IL056007516OtherLICENSE
ILP00796509OtherMEDICARE RR
IL214692008Medicare PIN
IL216860051Medicare PIN
IL056007516OtherLICENSE
ILF400173377Medicare PIN