Provider Demographics
NPI:1194967364
Name:D'AGOSTA, HEATHER (DPT)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:D'AGOSTA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:630-928-5080
Practice Address - Street 1:10020 PROFESSIONAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:MI
Practice Address - Zip Code:48139-0799
Practice Address - Country:US
Practice Address - Phone:810-893-7623
Practice Address - Fax:810-893-7624
Is Sole Proprietor?:No
Enumeration Date:2009-04-02
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014343225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN69750006Medicare PIN
MIMI6211037Medicare PIN