Provider Demographics
NPI:1689931099
Name:GRZYCH, BRE ANNA (LMT, LAC)
Entity Type:Individual
Prefix:
First Name:BRE
Middle Name:ANNA
Last Name:GRZYCH
Suffix:
Gender:F
Credentials:LMT, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8604 LEE ST
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-9631
Mailing Address - Country:US
Mailing Address - Phone:219-306-5950
Mailing Address - Fax:
Practice Address - Street 1:1395B MAIN ST
Practice Address - Street 2:
Practice Address - City:CRETE
Practice Address - State:IL
Practice Address - Zip Code:60417-2973
Practice Address - Country:US
Practice Address - Phone:708-672-6744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-23
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171100000X
IL227013095225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171100000XOther Service ProvidersAcupuncturist