Provider Demographics
NPI:1750459673
Name:WALICZEK, LAURA LYNN (DPT)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:LYNN
Last Name:WALICZEK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:LYNN
Other - Last Name:FESNAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:664 SW RUSTICA TERRACE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225
Mailing Address - Country:US
Mailing Address - Phone:503-902-2123
Mailing Address - Fax:
Practice Address - Street 1:9860 SW HALL BLVD
Practice Address - Street 2:#A3
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8896
Practice Address - Country:US
Practice Address - Phone:503-902-2123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4954225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist