Individual
MRS. KRISTA RUTH BOCK MANGAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
10523 S DRAKE AVE, CHICAGO, IL 60655
(773) 429-0103
Mailing address
12635 S 76TH AVE, PALOS HEIGHTS, IL 60463
(708) 912-5788
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
0560004157
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1626024
BLUE CROSS BLUE SHIELD IL
IL
Enumeration date
01/05/2007
Last updated
07/08/2007
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