Provider Demographics
NPI:1407577661
Name:RYSIEWICZ, MIRANDA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:RYSIEWICZ
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24014 W RENWICK RD UNIT 206
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-8711
Mailing Address - Country:US
Mailing Address - Phone:800-974-4378
Mailing Address - Fax:630-515-1536
Practice Address - Street 1:35376 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312-3514
Practice Address - Country:US
Practice Address - Phone:800-974-4378
Practice Address - Fax:630-515-1536
Is Sole Proprietor?:No
Enumeration Date:2022-09-07
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501301903225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist