Provider Demographics
NPI:1790153120
Name:SAGADORE, TAMARA (ATC)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:SAGADORE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 TRADERS CIR
Mailing Address - Street 2:APT 368A
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-4149
Mailing Address - Country:US
Mailing Address - Phone:309-532-0103
Mailing Address - Fax:
Practice Address - Street 1:180 N ADELAIDE ST
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2404
Practice Address - Country:US
Practice Address - Phone:309-438-3340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-02
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960037242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2-4778OtherCERTIFIED ATHLETIC THERAPIST CAT(C)