Provider Demographics
NPI:1821360355
Name:WENCLAWIAK, MICHAEL JEROME (PT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JEROME
Last Name:WENCLAWIAK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6067 GENTLEWIND CT
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-6316
Mailing Address - Country:US
Mailing Address - Phone:678-838-5194
Mailing Address - Fax:
Practice Address - Street 1:3999 AUSTELL RD.
Practice Address - Street 2:SUITE 701
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106
Practice Address - Country:US
Practice Address - Phone:770-739-0090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT003445225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist