Provider Demographics
NPI:1609425701
Name:POWROZEK, BRITTNEY MARQUEE
Entity Type:Individual
Prefix:
First Name:BRITTNEY
Middle Name:MARQUEE
Last Name:POWROZEK
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 1:4100 JUDD AVENUE
Mailing Address - Street 2:
Mailing Address - City:SCHILLER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60176-0001
Mailing Address - Country:US
Mailing Address - Phone:847-471-0979
Mailing Address - Fax:
Practice Address - Street 1:6820 MADRONE DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-9578
Practice Address - Country:US
Practice Address - Phone:480-313-6777
Practice Address - Fax:855-810-1930
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-10
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL347703225Medicaid