Provider Demographics
NPI:1568971133
Name:WIECZOREK, DEANETTE L (OTR)
Entity Type:Individual
Prefix:
First Name:DEANETTE
Middle Name:L
Last Name:WIECZOREK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:DEANETTE
Other - Middle Name:L
Other - Last Name:IGIELSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2157 CRISTINA ANNE CT
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48855-6309
Mailing Address - Country:US
Mailing Address - Phone:517-376-6651
Mailing Address - Fax:
Practice Address - Street 1:8542 W GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-2326
Practice Address - Country:US
Practice Address - Phone:734-449-4649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-26
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201004933225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist