Provider Demographics
NPI:1386913820
Name:WETTERSTRAND, MARY B (LAC)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:B
Last Name:WETTERSTRAND
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4024 WAGNER AVE
Mailing Address - Street 2:
Mailing Address - City:SCHILLER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60176-2108
Mailing Address - Country:US
Mailing Address - Phone:847-671-0149
Mailing Address - Fax:
Practice Address - Street 1:4024 WAGNER AVE
Practice Address - Street 2:
Practice Address - City:SCHILLER PARK
Practice Address - State:IL
Practice Address - Zip Code:60176-2108
Practice Address - Country:US
Practice Address - Phone:847-671-0149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-28
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.001031171100000X
225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist