Provider Demographics
NPI:1881662229
Name:WISNIEWSKI, MARY C (ATC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:WISNIEWSKI
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 1:5457 S KENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-5312
Mailing Address - Country:US
Mailing Address - Phone:773-288-0612
Mailing Address - Fax:
Practice Address - Street 1:5530 S ELLIS AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1402
Practice Address - Country:US
Practice Address - Phone:773-753-4708
Practice Address - Fax:773-834-4470
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer