Provider Demographics
NPI:1992481246
Name:4619 N. RAVENSWOOD AVE. SUITE 204 CHICAGO, IL 60640
Entity type:Organization
Organization Name:4619 N. RAVENSWOOD AVE. SUITE 204 CHICAGO, IL 60640
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPY ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:MAYA
Authorized Official - Middle Name:ELENA
Authorized Official - Last Name:E HOROWITZ
Authorized Official - Suffix:
Authorized Official - Credentials:COTA/L
Authorized Official - Phone:773-797-4155
Mailing Address - Street 1:4619 N RAVENSWOOD AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-4579
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4619 N RAVENSWOOD AVE STE 204
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-4579
Practice Address - Country:US
Practice Address - Phone:773-697-7333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-22
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty