Provider Demographics
NPI:1295444552
Name:GOGGIN, ROSEALEEN KELSI (PTA)
Entity type:Individual
Prefix:
First Name:ROSEALEEN
Middle Name:KELSI
Last Name:GOGGIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 RAND RD LOT 102
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-3433
Mailing Address - Country:US
Mailing Address - Phone:224-428-5165
Mailing Address - Fax:
Practice Address - Street 1:1409 W CARROLL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-1105
Practice Address - Country:US
Practice Address - Phone:312-733-0883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-15
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.009708225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant