Provider Demographics
NPI:1912266149
Name:BANEVICH-GLAROS, MELISSA JAYNE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:JAYNE
Last Name:BANEVICH-GLAROS
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 1:19350 BOULDER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8238
Mailing Address - Country:US
Mailing Address - Phone:708-257-1009
Mailing Address - Fax:
Practice Address - Street 1:19350 BOULDER RIDGE DR
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8238
Practice Address - Country:US
Practice Address - Phone:708-257-1009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-08
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL05605261314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility