Provider Demographics
NPI:1821597550
Name:PROVANCAL, MARIA ANNE (OTR/L)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:ANNE
Last Name:PROVANCAL
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 S HAWTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-3715
Mailing Address - Country:US
Mailing Address - Phone:630-202-3882
Mailing Address - Fax:
Practice Address - Street 1:1804 CENTRE POINT CIR
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-1440
Practice Address - Country:US
Practice Address - Phone:630-955-1940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-08
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.012310225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics