Provider Demographics
NPI:1871039677
Name:IACOBUCCI, MAURA KATHRYN (OTR/L)
Entity type:Individual
Prefix:
First Name:MAURA
Middle Name:KATHRYN
Last Name:IACOBUCCI
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 1:18 N CATHERINE AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-5930
Mailing Address - Country:US
Mailing Address - Phone:708-482-9453
Mailing Address - Fax:708-482-9454
Practice Address - Street 1:111 WASHINGTON ST FL 2
Practice Address - Street 2:
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-7796
Practice Address - Country:US
Practice Address - Phone:201-808-2245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-17
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025011225X00000X
NJ46TR00945900225X00000X
IL056011801225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1972691244OtherDO NOT TREAT MEDICAID OR MEDICARE PATIENTS