Provider Demographics
NPI:1376714808
Name:WALCZAK, RENEE LYN (RPT)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:LYN
Last Name:WALCZAK
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:LYN
Other - Last Name:RUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14112 KING ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66221-8004
Mailing Address - Country:US
Mailing Address - Phone:913-402-0651
Mailing Address - Fax:
Practice Address - Street 1:14112 KING ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66221-8004
Practice Address - Country:US
Practice Address - Phone:913-402-0651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-12
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-02133225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist