Provider Demographics
NPI:1205059714
Name:RAK, MARCY ATIA (SPEECH LANGUAGE PATH)
Entity type:Individual
Prefix:MRS
First Name:MARCY
Middle Name:ATIA
Last Name:RAK
Suffix:
Gender:F
Credentials:SPEECH LANGUAGE PATH
Other - Prefix:MRS
Other - First Name:MARCY
Other - Middle Name:ATIA
Other - Last Name:RAK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DEVELOPMENTAL THERAP
Mailing Address - Street 1:500 COPPER BEND ROAD
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5688
Mailing Address - Country:US
Mailing Address - Phone:618-792-3503
Mailing Address - Fax:618-288-9276
Practice Address - Street 1:500 COPPER BEND ROAD
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5688
Practice Address - Country:US
Practice Address - Phone:618-792-3503
Practice Address - Fax:618-288-9276
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist