Provider Demographics
NPI:1073060885
Name:GRYGUS, SARA
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:GRYGUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9048 LISCANOR AVE
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-9024
Mailing Address - Country:US
Mailing Address - Phone:708-833-0598
Mailing Address - Fax:
Practice Address - Street 1:9048 LISCANOR AVE
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-9024
Practice Address - Country:US
Practice Address - Phone:708-833-0598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-09
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILG622-7859-87062255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer