Provider Demographics
NPI:1063927184
Name:EITENMILLER, MELANIE A (MOT OTR/L)
Entity type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:A
Last Name:EITENMILLER
Suffix:
Gender:F
Credentials:MOT OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2217 SEPTEMBER LN
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-3043
Mailing Address - Country:US
Mailing Address - Phone:309-613-1298
Mailing Address - Fax:
Practice Address - Street 1:1010 N HOOKER ST STE 301
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-4633
Practice Address - Country:US
Practice Address - Phone:312-943-3600
Practice Address - Fax:312-943-3096
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-12
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.012284225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL056.012284Medicaid