Provider Demographics
NPI:1881807188
Name:EDWARDS, MARISSA LYNN (MS OTRL)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:LYNN
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:MS OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 WAUKEGAN RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-3070
Mailing Address - Country:US
Mailing Address - Phone:847-486-4140
Mailing Address - Fax:847-486-4145
Practice Address - Street 1:1308 WAUKEGAN RD
Practice Address - Street 2:SUITE 103
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-3070
Practice Address - Country:US
Practice Address - Phone:847-486-4140
Practice Address - Fax:847-486-4145
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.007898225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist