Provider Demographics
NPI:1346602554
Name:WITKOWSKI, ERICA
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:WITKOWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6N 370 CRESCENT LANE
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-1092
Mailing Address - Country:US
Mailing Address - Phone:845-699-4495
Mailing Address - Fax:
Practice Address - Street 1:6N 370 CRESCENT LANE
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175
Practice Address - Country:US
Practice Address - Phone:845-699-4495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-26
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer