Provider Demographics
NPI:1861086563
Name:VANMALDEGIAM, PATRICE M (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:PATRICE
Middle Name:M
Last Name:VANMALDEGIAM
Suffix:
Gender:F
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 1:925 WILKINSON LN
Mailing Address - Street 2:
Mailing Address - City:NORTH AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60542-8974
Mailing Address - Country:US
Mailing Address - Phone:630-308-1893
Mailing Address - Fax:
Practice Address - Street 1:2330 W GALENA BLVD
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-4246
Practice Address - Country:US
Practice Address - Phone:630-896-4686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057-001085224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant