Provider Demographics
NPI:1336757871
Name:GARCIA, MARISSA NICOLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:NICOLE
Last Name:GARCIA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 65TH ST
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60516-2941
Mailing Address - Country:US
Mailing Address - Phone:630-930-9443
Mailing Address - Fax:
Practice Address - Street 1:1400 BROOKDALE RD
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-2126
Practice Address - Country:US
Practice Address - Phone:630-416-6565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-21
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.013501225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist