Provider Demographics
NPI:1962613778
Name:KLECZEWSKI, JOHN E (OT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:KLECZEWSKI
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N4575 STATE HIGHWAY 32
Mailing Address - Street 2:
Mailing Address - City:KRAKOW
Mailing Address - State:WI
Mailing Address - Zip Code:54137-9087
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:430 MANOR DR
Practice Address - Street 2:
Practice Address - City:SURING
Practice Address - State:WI
Practice Address - Zip Code:54174-9182
Practice Address - Country:US
Practice Address - Phone:920-842-2191
Practice Address - Fax:920-842-2176
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3227026225X00000X
WI3227-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40894800Medicaid