Provider Demographics
NPI:1043367592
Name:BOCK MANGAN, KRISTA RUTH
Entity Type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:RUTH
Last Name:BOCK MANGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:RUTH
Other - Last Name:BOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTRL
Mailing Address - Street 1:12635 S 76TH AVE
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463
Mailing Address - Country:US
Mailing Address - Phone:708-912-5788
Mailing Address - Fax:
Practice Address - Street 1:10523 S DRAKE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655
Practice Address - Country:US
Practice Address - Phone:773-429-0103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0560004157225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1626024OtherBLUE CROSS BLUE SHIELD IL