Provider Demographics
NPI:1164595872
Name:AUGUSTO, MA GINA D
Entity Type:Individual
Prefix:
First Name:MA GINA
Middle Name:D
Last Name:AUGUSTO
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 1:1010 SANDERLING CT
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-6414
Mailing Address - Country:US
Mailing Address - Phone:847-395-7973
Mailing Address - Fax:847-395-7973
Practice Address - Street 1:1010 SANDERLING CT
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:IL
Practice Address - Zip Code:60002-6414
Practice Address - Country:US
Practice Address - Phone:847-395-7973
Practice Address - Fax:847-395-7973
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist