Healthcare Provider Details

I. General information

NPI: 1205142650
Provider Name (Legal Business Name): EMELYN B AGONCILLO PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EMELYN B BAUTISTA

II. Dates (important events)

Enumeration Date: 08/24/2010
Last Update Date: 10/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 HARRISON ST
BELLWOOD IL
60104-2450
US

IV. Provider business mailing address

2615 HARRISON ST
BELLWOOD IL
60104-2450
US

V. Phone/Fax

Practice location:
  • Phone: 708-493-0399
  • Fax: 708-493-9683
Mailing address:
  • Phone: 708-493-0399
  • Fax: 708-493-9683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070008627
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: