Provider Demographics
NPI:1124593959
Name:IWANICKI, MELISSA CATHERINE (PT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:CATHERINE
Last Name:IWANICKI
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 1:66 MILLER DR STE 102
Mailing Address - Street 2:
Mailing Address - City:NORTH AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60542-5144
Mailing Address - Country:US
Mailing Address - Phone:630-907-9165
Mailing Address - Fax:630-907-9195
Practice Address - Street 1:66 MILLER DR
Practice Address - Street 2:
Practice Address - City:NORTH AURORA
Practice Address - State:IL
Practice Address - Zip Code:60542-5143
Practice Address - Country:US
Practice Address - Phone:630-907-9165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.0117652251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics