Healthcare Provider Details

I. General information

NPI: 1306010889
Provider Name (Legal Business Name): SALLY KATSAGGELOS M.ED. CERT. AVT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2008
Last Update Date: 03/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5857 S. MARYLAND AVE. MC 9020
CHICAGO IL
60637-1470
US

IV. Provider business mailing address

714 W CORNELIA AVE
CHICAGO IL
60657-2400
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-8182
  • Fax: 773-834-0154
Mailing address:
  • Phone: 773-702-8182
  • Fax: 773-834-0154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: