Provider Demographics
NPI:1215778931
Name:BHAGAVATULA, ANIKA
Entity type:Individual
Prefix:
First Name:ANIKA
Middle Name:
Last Name:BHAGAVATULA
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 1:1266 SANDHURST DR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-6816
Mailing Address - Country:US
Mailing Address - Phone:630-363-1191
Mailing Address - Fax:
Practice Address - Street 1:1721 MOON LAKE BLVD STE 140
Practice Address - Street 2:
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60169-1070
Practice Address - Country:US
Practice Address - Phone:708-927-4127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty