Healthcare Provider Details

I. General information

NPI: 1578867214
Provider Name (Legal Business Name): AMBER M HAGARBOME PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMBER M VOGAN PT

II. Dates (important events)

Enumeration Date: 01/10/2011
Last Update Date: 06/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6459 US HIGHWAY 6
PORTAGE IN
46368-5109
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 219-762-5592
  • Fax:
Mailing address:
  • Phone: 630-296-2223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05010803A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: