Provider Demographics
NPI:1629279112
Name:CHUDZIK, AMY LOUISE (PT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LOUISE
Last Name:CHUDZIK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:LOUISE
Other - Last Name:CHUDZIK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:9553 JACKSON ST NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-2546
Mailing Address - Country:US
Mailing Address - Phone:763-780-4736
Mailing Address - Fax:
Practice Address - Street 1:22 27TH AVE SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-3102
Practice Address - Country:US
Practice Address - Phone:612-332-4262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4689171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor