Provider Demographics
NPI:1366540395
Name:PIASECKI, ANDREA M (PT)
Entity type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:M
Last Name:PIASECKI
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 1:5111 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-3681
Mailing Address - Country:US
Mailing Address - Phone:309-762-7979
Mailing Address - Fax:309-762-8094
Practice Address - Street 1:5111 22ND AVE
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-3681
Practice Address - Country:US
Practice Address - Phone:309-762-7979
Practice Address - Fax:309-762-7979
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070013907225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070-013907OtherILLINOIS PT LICENSE NUMBE
IL070-013907OtherILLINOIS PT LICENSE NUMBE
ILK13273Medicare PIN