Provider Demographics
NPI:1134141450
Name:KLATKIEWICZ, GREGORY J (PTGCS)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:KLATKIEWICZ
Suffix:
Gender:M
Credentials:PTGCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12588 S PARK RD
Mailing Address - Street 2:
Mailing Address - City:BUTTERNUT
Mailing Address - State:WI
Mailing Address - Zip Code:54514-8611
Mailing Address - Country:US
Mailing Address - Phone:715-769-3322
Mailing Address - Fax:
Practice Address - Street 1:250 LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:PARK FALLS
Practice Address - State:WI
Practice Address - Zip Code:54552-1431
Practice Address - Country:US
Practice Address - Phone:715-762-2449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1295-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40031700Medicaid
WI40031700Medicaid