Provider Demographics
NPI:1063969004
Name:NIERZWICKI, LOGAN N (PT)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:N
Last Name:NIERZWICKI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LOGAN
Other - Middle Name:N
Other - Last Name:BARTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:
Practice Address - Street 1:7341 A LAKE ST
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305
Practice Address - Country:US
Practice Address - Phone:708-763-0564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070022504225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist