Provider Demographics
NPI:1588077739
Name:WALCZYK, MAUREEN AUDREY
Entity type:Individual
Prefix:MRS
First Name:MAUREEN
Middle Name:AUDREY
Last Name:WALCZYK
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 1:8391 COMMERCE ROAD SUITE 106
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TWSP
Mailing Address - State:MI
Mailing Address - Zip Code:48382
Mailing Address - Country:US
Mailing Address - Phone:248-360-9881
Mailing Address - Fax:
Practice Address - Street 1:8391 COMMERCE RD STE 106
Practice Address - Street 2:
Practice Address - City:COMMERCE TWP
Practice Address - State:MI
Practice Address - Zip Code:48382-4489
Practice Address - Country:US
Practice Address - Phone:248-360-9881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-05
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501003948225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M15890Medicare PIN