Provider Demographics
NPI:1063687069
Name:BRANDON, MAE R (OT)
Entity type:Individual
Prefix:MRS
First Name:MAE
Middle Name:R
Last Name:BRANDON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:28 BRAEBURN DR
Mailing Address - Street 2:
Mailing Address - City:PARK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60466-2503
Mailing Address - Country:US
Mailing Address - Phone:708-481-2419
Mailing Address - Fax:708-481-6603
Practice Address - Street 1:3703 W LAKE AVE
Practice Address - Street 2:SUITE200
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-5823
Practice Address - Country:US
Practice Address - Phone:847-998-1188
Practice Address - Fax:847-998-8008
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056001180225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist