Provider Demographics
NPI:1922754415
Name:MAKO, KEITH S (OTR/L)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:S
Last Name:MAKO
Suffix:
Gender:M
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 1:790 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:
Mailing Address - Fax:
Practice Address - Street 1:285 BEISER BLVD STE 202
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-7804
Practice Address - Country:US
Practice Address - Phone:302-747-5995
Practice Address - Fax:302-244-0144
Is Sole Proprietor?:No
Enumeration Date:2022-02-23
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK188453225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK188453OtherLICENSE