Provider Demographics
NPI:1942370101
Name:KLEZEK, AMANDA (PT)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:KLEZEK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 N GLENVIEW CT
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60067-0628
Mailing Address - Country:US
Mailing Address - Phone:847-772-2312
Mailing Address - Fax:
Practice Address - Street 1:1010 N GLENVIEW CT
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60067-0628
Practice Address - Country:US
Practice Address - Phone:847-772-2312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01628190OtherBC BS OF ILLINOIS
ILAK99220496POtherEARLY INTERVENTION