Provider Demographics
NPI:1467861088
Name:RAGUSA, AMANDA ELIZABETH
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:ELIZABETH
Last Name:RAGUSA
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:ELIZABETH
Other - Last Name:BELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2604 W JOHNSBURG RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60051-5105
Mailing Address - Country:US
Mailing Address - Phone:815-578-1771
Mailing Address - Fax:
Practice Address - Street 1:2604 W JOHNSBURG RD
Practice Address - Street 2:
Practice Address - City:JOHNSBURG
Practice Address - State:IL
Practice Address - Zip Code:60051-5105
Practice Address - Country:US
Practice Address - Phone:815-578-1771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.011839225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist