Provider Demographics
NPI:1629676481
Name:BAGDASARIAN, DONNA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:BAGDASARIAN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1765 N ELSTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-1501
Mailing Address - Country:US
Mailing Address - Phone:847-508-8677
Mailing Address - Fax:
Practice Address - Street 1:1765 N ELSTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-1501
Practice Address - Country:US
Practice Address - Phone:847-508-8677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0700253312251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty