Individual
MR. JEFFERSON JAMES MAHINAY LICUP
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
OTR/L
Contact information
Practice address
226 TIGER ST, BOLINGBROOK, IL 60490-2053
(708) 822-8886
(630) 378-4839
Mailing address
226 TIGER ST, BOLINGBROOK, IL 60490-2053
(708) 822-8886
(630) 378-4839
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
056007185
IL
Other
Enumeration date
10/13/2009
Last updated
10/13/2009
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