Provider Demographics
NPI:1417025651
Name:WALCZAK, NICOLE (PT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WALCZAK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:GRONKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:260 E ARMY TRAIL RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103
Mailing Address - Country:US
Mailing Address - Phone:630-830-8600
Mailing Address - Fax:630-830-2273
Practice Address - Street 1:260 E ARMY TRAIL RD
Practice Address - Street 2:SUITE D
Practice Address - City:BARTLETT
Practice Address - State:IL
Practice Address - Zip Code:60103
Practice Address - Country:US
Practice Address - Phone:630-830-8600
Practice Address - Fax:630-830-2273
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
K19397Medicare ID - Type Unspecified