Provider Demographics
NPI:1497253223
Name:MITACEK, TAYLOR (DPT)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:MITACEK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 YORK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1925
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:241 SE DESTINATION DR
Practice Address - Street 2:
Practice Address - City:GRIMES
Practice Address - State:IA
Practice Address - Zip Code:50111-1247
Practice Address - Country:US
Practice Address - Phone:515-986-5190
Practice Address - Fax:515-986-5194
Is Sole Proprietor?:No
Enumeration Date:2018-01-26
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA123558225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty