Provider Demographics
NPI:1689292278
Name:FOREMAN, AGATA M
Entity Type:Individual
Prefix:
First Name:AGATA
Middle Name:M
Last Name:FOREMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6420 LAKEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:IL
Mailing Address - Zip Code:60013-1239
Mailing Address - Country:US
Mailing Address - Phone:224-704-9218
Mailing Address - Fax:
Practice Address - Street 1:333 COMMERCE DR STE 175
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-3596
Practice Address - Country:US
Practice Address - Phone:224-704-9218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL02.021803225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty