Provider Demographics
NPI:1255450292
Name:PARKS, MARY JANE (LMT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:PARKS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3044 E COUNTY HIGHWAY 31
Mailing Address - Street 2:
Mailing Address - City:DONOVAN
Mailing Address - State:IL
Mailing Address - Zip Code:60931-6031
Mailing Address - Country:US
Mailing Address - Phone:815-429-3698
Mailing Address - Fax:
Practice Address - Street 1:819 W LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:WATSEKA
Practice Address - State:IL
Practice Address - Zip Code:60970-1081
Practice Address - Country:US
Practice Address - Phone:815-432-1145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist