Provider Demographics
NPI:1134435415
Name:PUUSEPT ZAGONE, EVELIN
Entity type:Individual
Prefix:
First Name:EVELIN
Middle Name:
Last Name:PUUSEPT ZAGONE
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 1:3423 1/2 N NEWCASTLE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-3754
Mailing Address - Country:US
Mailing Address - Phone:773-849-2234
Mailing Address - Fax:
Practice Address - Street 1:3423 1/2 N NEWCASTLE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-3754
Practice Address - Country:US
Practice Address - Phone:773-849-2234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-25
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227011133225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist