Provider Demographics
NPI:1649527672
Name:CLEGGETT, RETUNJA L (OT)
Entity type:Individual
Prefix:
First Name:RETUNJA
Middle Name:L
Last Name:CLEGGETT
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3847 W. 95TH STREET
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805
Mailing Address - Country:US
Mailing Address - Phone:708-422-4441
Mailing Address - Fax:708-422-2122
Practice Address - Street 1:3847 W. 95TH STREET
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-0000
Practice Address - Country:US
Practice Address - Phone:708-422-4441
Practice Address - Fax:708-422-2122
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056003910225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL056003910OtherIDFPR-IL