Provider Demographics
NPI:1952868085
Name:PRUSA, ANGELA MARIE (ATC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:PRUSA
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 1:309 STRATFORD PL APT 31
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-2382
Mailing Address - Country:US
Mailing Address - Phone:630-863-2011
Mailing Address - Fax:
Practice Address - Street 1:550 W OGDEN AVE
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3186
Practice Address - Country:US
Practice Address - Phone:630-863-2011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960043192255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty