Provider Demographics
NPI:1053633990
Name:DALAGAN, SAMUEL (PT)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:DALAGAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 DOGWOOD LN
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-5860
Mailing Address - Country:US
Mailing Address - Phone:618-548-8695
Mailing Address - Fax:
Practice Address - Street 1:19 DOGWOOD LN
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-5860
Practice Address - Country:US
Practice Address - Phone:618-548-8695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-19
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.007315225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist