Provider Demographics
NPI:1780707612
Name:ABREGO, MARICELA (OT)
Entity type:Individual
Prefix:
First Name:MARICELA
Middle Name:
Last Name:ABREGO
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 1:5449 W WRIGHTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-1456
Mailing Address - Country:US
Mailing Address - Phone:773-615-5239
Mailing Address - Fax:
Practice Address - Street 1:5449 W WRIGHTWOOD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-1456
Practice Address - Country:US
Practice Address - Phone:773-615-5239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.005516225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL344600424001Medicaid
ILMA04200200POtherE.I. CREDENTIAL NUMBER