Provider Demographics
NPI:1306010889
Name:KATSAGGELOS, SALLY (MED CERT AVT)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:
Last Name:KATSAGGELOS
Suffix:
Gender:F
Credentials:MED CERT AVT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 W CORNELIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-2400
Mailing Address - Country:US
Mailing Address - Phone:773-702-8182
Mailing Address - Fax:773-834-0154
Practice Address - Street 1:5857 S. MARYLAND AVE.
Practice Address - Street 2:MC 9020
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1470
Practice Address - Country:US
Practice Address - Phone:773-702-8182
Practice Address - Fax:773-834-0154
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-16
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner