Provider Demographics
NPI:1942245535
Name:MALLIARAS, EVELYN CARMEN (MS)
Entity Type:Individual
Prefix:MRS
First Name:EVELYN
Middle Name:CARMEN
Last Name:MALLIARAS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5820 N NAGLE AVE
Mailing Address - Street 2:UNIT G.
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-5344
Mailing Address - Country:US
Mailing Address - Phone:773-774-1990
Mailing Address - Fax:773-792-8119
Practice Address - Street 1:5820 N NAGLE AVE
Practice Address - Street 2:UNIT G.
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-5344
Practice Address - Country:US
Practice Address - Phone:773-774-1990
Practice Address - Fax:773-792-8119
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL56007460225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist