Provider Demographics
NPI:1639806417
Name:BESOUGLOFF, TATE
Entity type:Individual
Prefix:
First Name:TATE
Middle Name:
Last Name:BESOUGLOFF
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 1:2001 BUTTERFIELD RD STE 1600
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1242 STATE AVE STE A
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-3672
Practice Address - Country:US
Practice Address - Phone:360-572-5800
Practice Address - Fax:360-454-9043
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA303980225100000X
WA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist