Provider Demographics
NPI:1902355449
Name:HATAKEYAMA, MARISA
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:HATAKEYAMA
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 1:412 JASON LN
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-2053
Mailing Address - Country:US
Mailing Address - Phone:847-571-7570
Mailing Address - Fax:
Practice Address - Street 1:412 JASON LN
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173-2053
Practice Address - Country:US
Practice Address - Phone:847-571-7570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146013206235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist