Provider Demographics
NPI:1992705842
Name:SUDHAKAR, HEPHZIBAH (PT)
Entity type:Individual
Prefix:MRS
First Name:HEPHZIBAH
Middle Name:
Last Name:SUDHAKAR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:HEPHZIBAH
Other - Middle Name:
Other - Last Name:AUGUSTINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:765 N KELLOGG ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-2875
Mailing Address - Country:US
Mailing Address - Phone:309-343-3434
Mailing Address - Fax:309-343-3456
Practice Address - Street 1:765 N KELLOGG ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-2875
Practice Address - Country:US
Practice Address - Phone:309-343-3434
Practice Address - Fax:309-343-3456
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL327900119001Medicaid
IL327900119001Medicaid