Basic Information
| Provider Information | |||||||||
| NPI: | 1275784175 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACK | ||||||||
| FirstName: | MARY JO | ||||||||
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| Credential: | KT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1163 POPES CREEK CIR | ||||||||
| Address2: | |||||||||
| City: | GRAYSLAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600301142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475485186 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3001 GREENBAY | ||||||||
| Address2: | |||||||||
| City: | NORTH CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476881900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2008 | ||||||||
| LastUpdateDate: | 10/09/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 226300000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Kinesiotherapist |
No ID Information.