Provider Demographics
NPI:1568637593
Name:WACHEWICZ, LUCAS JAY (PT)
Entity Type:Individual
Prefix:MR
First Name:LUCAS
Middle Name:JAY
Last Name:WACHEWICZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 W CLAIREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-4503
Mailing Address - Country:US
Mailing Address - Phone:715-471-0954
Mailing Address - Fax:844-829-7001
Practice Address - Street 1:1101 W CLAIREMONT AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-4503
Practice Address - Country:US
Practice Address - Phone:715-471-0954
Practice Address - Fax:844-829-7001
Is Sole Proprietor?:No
Enumeration Date:2008-04-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10424-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1568637593Medicaid