Provider Demographics
NPI:1063953495
Name:MACIEL-MALDONADO, LUIS ALBERTO (COTA/L)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:ALBERTO
Last Name:MACIEL-MALDONADO
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4516 W 55TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60632-4722
Mailing Address - Country:US
Mailing Address - Phone:773-691-2640
Mailing Address - Fax:773-475-7564
Practice Address - Street 1:3000 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-4458
Practice Address - Country:US
Practice Address - Phone:773-475-7651
Practice Address - Fax:773-475-7564
Is Sole Proprietor?:No
Enumeration Date:2017-03-18
Last Update Date:2017-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.004693224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant