Provider Demographics
NPI:1134383557
Name:THAYER, MARY PATRICIA (LAC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:PATRICIA
Last Name:THAYER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7033 N SHERIDAN RD
Mailing Address - Street 2:UNIT #3-N
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-3088
Mailing Address - Country:US
Mailing Address - Phone:773-338-2871
Mailing Address - Fax:338-338-2877
Practice Address - Street 1:7033 N SHERIDAN RD
Practice Address - Street 2:UNIT #3-N
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-3088
Practice Address - Country:US
Practice Address - Phone:773-338-2871
Practice Address - Fax:773-338-2877
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-15
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.000735171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor