MEDICARE: CORAZON RAPOSA AGRAVANTE D.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1447410063
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CORAZON RAPOSA AGRAVANTE D.T.

Provider Business Mailing Address
First Line	:	1926 W HARRISON ST
Second Line	:	APT. 211
City	:	CHICAGO
State	:	IL
Zip	:	60612-3737
Country	:	US
Telephone Number	:	856-313-1386
Fax Number	:	312-864-9336

Provider Business Practice Location Address
First Line	:	1926 W HARRISON ST
Second Line	:	APT. 211
City	:	CHICAGO
State	:	IL
Zip	:	60612-3737
Country	:	US
Telephone Number	:	856-313-1386
Fax Number	:	312-864-9336

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2008
Last Update Date	:	06/17/2008

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