Healthcare Provider Details

I. General information

NPI: 1164022588
Provider Name (Legal Business Name): MARY KATE ZAGOTTA M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2020
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 W KINZIE ST APT 1608
CHICAGO IL
60654-5847
US

IV. Provider business mailing address

555 W KINZIE ST APT 1608
CHICAGO IL
60654-5847
US

V. Phone/Fax

Practice location:
  • Phone: 708-724-3951
  • Fax:
Mailing address:
  • Phone: 708-724-3951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number14094724
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: