Provider Demographics
NPI:1194294413
Name:ROETHLISBERGER, MARGO
Entity type:Individual
Prefix:
First Name:MARGO
Middle Name:
Last Name:ROETHLISBERGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 CHELSEA AVE
Mailing Address - Street 2:
Mailing Address - City:SUGAR GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60554-5407
Mailing Address - Country:US
Mailing Address - Phone:217-737-2962
Mailing Address - Fax:
Practice Address - Street 1:3330 W 177TH ST STE 1F
Practice Address - Street 2:
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-2186
Practice Address - Country:US
Practice Address - Phone:708-745-3040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
IL180002364101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator