Provider Demographics
NPI:1154768232
Name:WALCZAK, KALLIE (PT)
Entity type:Individual
Prefix:
First Name:KALLIE
Middle Name:
Last Name:WALCZAK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 S SWEETBRIAR DR
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:IL
Mailing Address - Zip Code:61523-2264
Mailing Address - Country:US
Mailing Address - Phone:309-274-6314
Mailing Address - Fax:309-274-4100
Practice Address - Street 1:525 S SWEETBRIAR DR
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:IL
Practice Address - Zip Code:61523-2264
Practice Address - Country:US
Practice Address - Phone:309-274-6314
Practice Address - Fax:309-274-4100
Is Sole Proprietor?:No
Enumeration Date:2013-05-29
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist