Provider Demographics
NPI:1205030616
Name:BAGACINA, MARIANNE BERNARDO (PT)
Entity Type:Individual
Prefix:MISS
First Name:MARIANNE
Middle Name:BERNARDO
Last Name:BAGACINA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 W ARGYLE ST.
Mailing Address - Street 2:UNIT 1-E
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640
Mailing Address - Country:US
Mailing Address - Phone:773-575-3399
Mailing Address - Fax:
Practice Address - Street 1:1330 W ARGYLE ST
Practice Address - Street 2:UNIT 1-E
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-4713
Practice Address - Country:US
Practice Address - Phone:773-575-3399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070015341225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070015341OtherPHYSICAL THERAPY LIC., IL
IN05008692OtherINDIANA PHYSICAL THERAPY BOARD