Provider Demographics
NPI:1073973855
Name:WASYLK, DANIEL TODD
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:TODD
Last Name:WASYLK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11111 HOAGLAND RD
Mailing Address - Street 2:
Mailing Address - City:HOAGLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46745-9582
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11130 PARKVIEW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1735
Practice Address - Country:US
Practice Address - Phone:260-710-1908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001783A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer