Provider Demographics
NPI:1063156677
Name:BAGBY, SONNY YEVON
Entity type:Individual
Prefix:
First Name:SONNY
Middle Name:YEVON
Last Name:BAGBY
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 1:440 TATHAM LN
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:IL
Mailing Address - Zip Code:62995-2828
Mailing Address - Country:US
Mailing Address - Phone:618-771-2648
Mailing Address - Fax:
Practice Address - Street 1:440 TATHAM LN
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:IL
Practice Address - Zip Code:62995-2828
Practice Address - Country:US
Practice Address - Phone:618-771-2648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057003475224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant