Provider Demographics
NPI:1538690060
Name:GICZEWSKI, SUSAN (COTA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:GICZEWSKI
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 CAMELOT EST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-5203
Mailing Address - Country:US
Mailing Address - Phone:219-940-3507
Mailing Address - Fax:
Practice Address - Street 1:119 N INDIANA AVE
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-4112
Practice Address - Country:US
Practice Address - Phone:219-663-2532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-26
Last Update Date:2017-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002765A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant