Provider Demographics
NPI:1386295863
Name:RAYBON, CHANEL
Entity type:Individual
Prefix:
First Name:CHANEL
Middle Name:
Last Name:RAYBON
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:PO BOX 405
Mailing Address - Street 2:
Mailing Address - City:MARKHAM
Mailing Address - State:IL
Mailing Address - Zip Code:60428-0405
Mailing Address - Country:US
Mailing Address - Phone:708-515-0813
Mailing Address - Fax:
Practice Address - Street 1:16726 ORCHARD RIDGE AVE
Practice Address - Street 2:
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-1242
Practice Address - Country:US
Practice Address - Phone:708-515-0813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-25
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057005228224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL057005228OtherLICENSE
IL057005228OtherSTATE LICENSE