Provider Demographics
NPI:1598512246
Name:WIELGOPOLAN, KYLIE (OT, CHT)
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:WIELGOPOLAN
Suffix:
Gender:F
Credentials:OT, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2491 INDUSTRIAL CT STE 100
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-1365
Mailing Address - Country:US
Mailing Address - Phone:815-488-8040
Mailing Address - Fax:
Practice Address - Street 1:4996 ILLINOIS ROUTE 159
Practice Address - Street 2:SUITE B
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062
Practice Address - Country:US
Practice Address - Phone:618-288-4677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-01
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056010241225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand