Healthcare Provider Details

I. General information

NPI: 1225358062
Provider Name (Legal Business Name): CANDACE BUGGS MOTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2010
Last Update Date: 04/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4538 N BEACON ST
CHICAGO IL
60640-5519
US

IV. Provider business mailing address

4538 N BEACON ST
CHICAGO IL
60640-5519
US

V. Phone/Fax

Practice location:
  • Phone: 773-275-7200
  • Fax:
Mailing address:
  • Phone: 773-275-7200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056.007619
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: