Provider Demographics
NPI:1205142650
Name:AGONCILLO, EMELYN B (PT)
Entity type:Individual
Prefix:
First Name:EMELYN
Middle Name:B
Last Name:AGONCILLO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:EMELYN
Other - Middle Name:B
Other - Last Name:BAUTISTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2615 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:BELLWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60104-2450
Mailing Address - Country:US
Mailing Address - Phone:708-493-0399
Mailing Address - Fax:708-493-9683
Practice Address - Street 1:2615 HARRISON ST
Practice Address - Street 2:
Practice Address - City:BELLWOOD
Practice Address - State:IL
Practice Address - Zip Code:60104-2450
Practice Address - Country:US
Practice Address - Phone:708-493-0399
Practice Address - Fax:708-493-9683
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070008627225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist