Provider Demographics
NPI:1154192094
Name:ZDZIEBLOWSKI, NYLES MARK
Entity type:Individual
Prefix:
First Name:NYLES
Middle Name:MARK
Last Name:ZDZIEBLOWSKI
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 1:765 S GREY RD
Mailing Address - Street 2:
Mailing Address - City:AUBURN HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48326-3817
Mailing Address - Country:US
Mailing Address - Phone:414-315-2040
Mailing Address - Fax:
Practice Address - Street 1:26715 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-4717
Practice Address - Country:US
Practice Address - Phone:248-557-0050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI520103568225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist