Provider Demographics
NPI:1992978175
Name:SPAGNOLA, TRAVIS J
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:J
Last Name:SPAGNOLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1816 170TH ST
Mailing Address - Street 2:
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429-1451
Mailing Address - Country:US
Mailing Address - Phone:708-335-1415
Mailing Address - Fax:708-335-0115
Practice Address - Street 1:17236 HARLEM AVE
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-6619
Practice Address - Country:US
Practice Address - Phone:708-633-8379
Practice Address - Fax:708-633-8614
Is Sole Proprietor?:No
Enumeration Date:2008-04-08
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070016338225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist