Provider Demographics
NPI:1205383775
Name:WALKOWIAK, NIKODEM
Entity Type:Individual
Prefix:
First Name:NIKODEM
Middle Name:
Last Name:WALKOWIAK
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 1:1730 EFFINGHAM STR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526
Mailing Address - Country:US
Mailing Address - Phone:773-742-7428
Mailing Address - Fax:
Practice Address - Street 1:1730 EFFINGHAM ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-2343
Practice Address - Country:US
Practice Address - Phone:773-742-7428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOTA.0000771224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant