Provider Demographics
NPI:1083219596
Name:KACZKOWSKI, NICHOLAS (PT, DPT, MS)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:KACZKOWSKI
Suffix:
Gender:M
Credentials:PT, DPT, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3921 30TH AVE STE C
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1939
Mailing Address - Country:US
Mailing Address - Phone:262-925-5004
Mailing Address - Fax:262-925-5001
Practice Address - Street 1:145 SAYTON RD STE F
Practice Address - Street 2:
Practice Address - City:FOX LAKE
Practice Address - State:IL
Practice Address - Zip Code:60020-1773
Practice Address - Country:US
Practice Address - Phone:847-629-5536
Practice Address - Fax:847-529-5163
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070025353225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist