Provider Demographics
NPI:1699959718
Name:EDSTROM, MARIE CHRISTINE (LMT, NCTMB)
Entity type:Individual
Prefix:MS
First Name:MARIE
Middle Name:CHRISTINE
Last Name:EDSTROM
Suffix:
Gender:F
Credentials:LMT, NCTMB
Other - Prefix:MRS
Other - First Name:MARIE
Other - Middle Name:CHRISTINE
Other - Last Name:COURTNEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3521 EUCLID AVE
Mailing Address - Street 2:APT 2
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-4731
Mailing Address - Country:US
Mailing Address - Phone:405-999-6016
Mailing Address - Fax:
Practice Address - Street 1:3521 EUCLID AVE
Practice Address - Street 2:APT 2
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-4731
Practice Address - Country:US
Practice Address - Phone:405-999-6016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-26
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.008701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist