Provider Demographics
NPI:1457682510
Name:SOUDAGAR, PRIYANKA
Entity Type:Individual
Prefix:
First Name:PRIYANKA
Middle Name:
Last Name:SOUDAGAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PRIYANKA
Other - Middle Name:
Other - Last Name:MALLIK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7500 GLADSTONE DR
Mailing Address - Street 2:APT 101
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60565-2646
Mailing Address - Country:US
Mailing Address - Phone:312-927-3103
Mailing Address - Fax:
Practice Address - Street 1:6300 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2256
Practice Address - Country:US
Practice Address - Phone:708-599-2215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-28
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.008018225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist