Provider Demographics
NPI:1962757393
Name:WIETRZYKOWSKI, CHRISTINE MARIE (PT)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:MARIE
Last Name:WIETRZYKOWSKI
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 1:39W651 HOWARD SQ
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-4433
Mailing Address - Country:US
Mailing Address - Phone:630-208-0627
Mailing Address - Fax:
Practice Address - Street 1:300 RANDALL RD
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-4200
Practice Address - Country:US
Practice Address - Phone:630-208-4592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.009214225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist