Provider Demographics
NPI:1801291216
Name:BAGUS, AMANDA KATHLEEN (ATC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:KATHLEEN
Last Name:BAGUS
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 1:832 N WASHTENAW AVE
Mailing Address - Street 2:UNIT 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-4429
Mailing Address - Country:US
Mailing Address - Phone:630-346-1742
Mailing Address - Fax:866-954-5808
Practice Address - Street 1:680 N LAKE SHORE DR
Practice Address - Street 2:SUITE 924
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4546
Practice Address - Country:US
Practice Address - Phone:312-664-6848
Practice Address - Fax:866-954-5808
Is Sole Proprietor?:No
Enumeration Date:2014-10-28
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960027902255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer