Provider Demographics
NPI:1578859948
Name:WACHALA, JUSTYNA M
Entity Type:Individual
Prefix:
First Name:JUSTYNA
Middle Name:M
Last Name:WACHALA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 N. HOOKER STREET
Mailing Address - Street 2:SUITE 301
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-4633
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1010 N. HOOKER STREET
Practice Address - Street 2:SUITE 301
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-4633
Practice Address - Country:US
Practice Address - Phone:312-943-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242001904235Z00000X
IL146011117235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist