Provider Demographics
NPI:1992312631
Name:BIS, AGNIESZKA WANDA (COTA/ L)
Entity type:Individual
Prefix:
First Name:AGNIESZKA
Middle Name:WANDA
Last Name:BIS
Suffix:
Gender:F
Credentials:COTA/ L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 FREDERICK LN
Mailing Address - Street 2:
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60169-4813
Mailing Address - Country:US
Mailing Address - Phone:773-965-0030
Mailing Address - Fax:
Practice Address - Street 1:110 W SCHAUMBURG RD
Practice Address - Street 2:
Practice Address - City:STREAMWOOD
Practice Address - State:IL
Practice Address - Zip Code:60107-1459
Practice Address - Country:US
Practice Address - Phone:630-444-7087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-27
Last Update Date:2020-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.002843224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant