Provider Demographics
NPI:1003049073
Name:STANCZAK, KELLY (DPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:STANCZAK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:SHIELDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:625 ENTERPRISE DR.
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-6250
Mailing Address - Fax:630-575-7450
Practice Address - Street 1:225 E DEERPATH
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1952
Practice Address - Country:US
Practice Address - Phone:847-482-1433
Practice Address - Fax:847-482-1483
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2017-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-017373225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist