Provider Demographics
NPI:1215492996
Name:WIETRZYKOWSKI, STEVEN ALEXANDER (PT, DPT, CSCS)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:ALEXANDER
Last Name:WIETRZYKOWSKI
Suffix:
Gender:M
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5418 SW 4TH PL
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-2013
Mailing Address - Country:US
Mailing Address - Phone:419-764-3427
Mailing Address - Fax:
Practice Address - Street 1:4650 NW 39TH PLACE
Practice Address - Street 2:SUITE A
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606
Practice Address - Country:US
Practice Address - Phone:352-225-3610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT335902251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports