Provider Demographics
NPI:1477729010
Name:WICZYNSKI, JACEK MARIAN (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:JACEK
Middle Name:MARIAN
Last Name:WICZYNSKI
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 CEDAR LN
Mailing Address - Street 2:
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-4318
Mailing Address - Country:US
Mailing Address - Phone:516-607-3334
Mailing Address - Fax:
Practice Address - Street 1:161 CEDAR LN
Practice Address - Street 2:
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702-4318
Practice Address - Country:US
Practice Address - Phone:631-650-1849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-04
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012200-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist