Provider Demographics
NPI:1669723128
Name:MCDONNELL, LAUREN (MOTR/L)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:MCDONNELL
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:
Other - Last Name:FASAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MOTR/L
Mailing Address - Street 1:10815 S FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-1722
Mailing Address - Country:US
Mailing Address - Phone:708-369-8494
Mailing Address - Fax:
Practice Address - Street 1:9806 S TURNER AVE
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-3053
Practice Address - Country:US
Practice Address - Phone:708-369-8494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-25
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.009262225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist