Provider Demographics
NPI:1700112166
Name:MARKS, MARA (OT)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:MARKS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 E WATERSIDE DR
Mailing Address - Street 2:#308
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-8001
Mailing Address - Country:US
Mailing Address - Phone:956-661-0475
Mailing Address - Fax:
Practice Address - Street 1:2157 N DAMEN AVE
Practice Address - Street 2:SUITE 2C
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-6916
Practice Address - Country:US
Practice Address - Phone:773-278-4769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-20
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056004837225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45-497Medicaid