Provider Demographics
NPI:1548599707
Name:NISSEN, MARY (OTR/L)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:NISSEN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1932 W CRYSTAL ST
Mailing Address - Street 2:UNIT 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-3132
Mailing Address - Country:US
Mailing Address - Phone:847-784-9115
Mailing Address - Fax:847-784-9330
Practice Address - Street 1:328 N SHADDLE AVE
Practice Address - Street 2:
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-2411
Practice Address - Country:US
Practice Address - Phone:847-566-9860
Practice Address - Fax:847-566-9861
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-17
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-007166174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist