Provider Demographics
NPI:1447410063
Name:AGRAVANTE, CORAZON RAPOSA (DT)
Entity Type:Individual
Prefix:
First Name:CORAZON
Middle Name:RAPOSA
Last Name:AGRAVANTE
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1926 W HARRISON ST
Mailing Address - Street 2:APT. 211
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3737
Mailing Address - Country:US
Mailing Address - Phone:856-313-1386
Mailing Address - Fax:312-864-9336
Practice Address - Street 1:1926 W HARRISON ST
Practice Address - Street 2:APT. 211
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3737
Practice Address - Country:US
Practice Address - Phone:856-313-1386
Practice Address - Fax:312-864-9336
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$OtherSSN