Provider Demographics
NPI:1083080303
Name:GRYGLAK, AGATHA (PTA)
Entity Type:Individual
Prefix:
First Name:AGATHA
Middle Name:
Last Name:GRYGLAK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10001 DERBY LN
Mailing Address - Street 2:SUITE 208
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-3749
Mailing Address - Country:US
Mailing Address - Phone:708-681-2991
Mailing Address - Fax:708-731-3173
Practice Address - Street 1:10233 W ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:WESTCHESTER
Practice Address - State:IL
Practice Address - Zip Code:60154-2518
Practice Address - Country:US
Practice Address - Phone:708-938-5238
Practice Address - Fax:708-938-5239
Is Sole Proprietor?:No
Enumeration Date:2015-08-20
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160007177225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant