Provider Demographics
NPI:1215620265
Name:MAZURKIEWICZ KUBOWICZ, AGNIESZKA R
Entity type:Individual
Prefix:
First Name:AGNIESZKA
Middle Name:R
Last Name:MAZURKIEWICZ KUBOWICZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 WISTERIA DR
Mailing Address - Street 2:
Mailing Address - City:STREAMWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60107-2213
Mailing Address - Country:US
Mailing Address - Phone:630-441-0435
Mailing Address - Fax:
Practice Address - Street 1:4515 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-3711
Practice Address - Country:US
Practice Address - Phone:312-671-4111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist