Provider Demographics
NPI:1013100478
Name:MALIWAT, MICHELLE O (DPT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:O
Last Name:MALIWAT
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9375 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-4271
Mailing Address - Country:US
Mailing Address - Phone:847-824-5165
Mailing Address - Fax:847-824-8038
Practice Address - Street 1:9375 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-4271
Practice Address - Country:US
Practice Address - Phone:847-824-5165
Practice Address - Fax:847-824-8038
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL362169147-60635-01Medicaid