Provider Demographics
NPI:1023536877
Name:WIECZOREK, MARY HELEN (ATC/LAT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:HELEN
Last Name:WIECZOREK
Suffix:
Gender:F
Credentials:ATC/LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4050 S LAKE DR APT 3
Mailing Address - Street 2:
Mailing Address - City:ST FRANCIS
Mailing Address - State:WI
Mailing Address - Zip Code:53235-5255
Mailing Address - Country:US
Mailing Address - Phone:414-759-1773
Mailing Address - Fax:414-288-6477
Practice Address - Street 1:770 N 12TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-2203
Practice Address - Country:US
Practice Address - Phone:414-288-0328
Practice Address - Fax:414-288-6477
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1420-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer