Provider Demographics
NPI:1952326720
Name:JARELL-GRACIOUS, MARIE (PT)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:JARELL-GRACIOUS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 VANDERBILT DR
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-3826
Mailing Address - Country:US
Mailing Address - Phone:708-359-1989
Mailing Address - Fax:
Practice Address - Street 1:701 VANDERBILT DR
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-3826
Practice Address - Country:US
Practice Address - Phone:708-359-1989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-005355225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1623066OtherBCBS PROVIDER NUMBER
IL367885100OtherUS DEPT OF LABOR
IL567770Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER