Provider Demographics
NPI:1700334257
Name:DHAMIJA, MRIDULA
Entity Type:Individual
Prefix:MISS
First Name:MRIDULA
Middle Name:
Last Name:DHAMIJA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3839 N KEYSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-3124
Mailing Address - Country:US
Mailing Address - Phone:859-582-4742
Mailing Address - Fax:
Practice Address - Street 1:3839 N KEYSTONE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-3124
Practice Address - Country:US
Practice Address - Phone:859-582-4742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056011458225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist