Provider Demographics
NPI:1629355219
Name:JUZESZYN, LAURA (ATC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:JUZESZYN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 S MAPLE ST
Mailing Address - Street 2:P.O. BOX 184
Mailing Address - City:CLIFTON
Mailing Address - State:IL
Mailing Address - Zip Code:60927-9411
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:567 N 5TH ST
Practice Address - Street 2:SS 172
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47809-1903
Practice Address - Country:US
Practice Address - Phone:812-237-9613
Practice Address - Fax:812-237-9612
Is Sole Proprietor?:No
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001878A2255A2300X
IL096.0031732255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer