Provider Demographics
NPI:1518357656
Name:BONGARALA, VENKATA JAYA MADHURI (PT)
Entity Type:Individual
Prefix:
First Name:VENKATA
Middle Name:JAYA MADHURI
Last Name:BONGARALA
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 1:255 THRUSH CIR
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60046-7949
Mailing Address - Country:US
Mailing Address - Phone:847-668-4744
Mailing Address - Fax:
Practice Address - Street 1:3001 GREEN BAY RD
Practice Address - Street 2:CAPTAIN JAMES A. LOVELL FEDERAL HEALTH CARE CENTER
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064-3048
Practice Address - Country:US
Practice Address - Phone:224-619-5114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-27
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070011570225100000X
IN05006453A225100000X
NJ40QA00867600225100000X
MI5501008631225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist