Provider Demographics
NPI:1336164177
Name:KLISZ, ANGELA L (DPT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:L
Last Name:KLISZ
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MISS
Other - First Name:ANGELA
Other - Middle Name:L
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21075 SWENSON DR
Mailing Address - Street 2:STE 600
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-2062
Mailing Address - Country:US
Mailing Address - Phone:312-640-0329
Mailing Address - Fax:
Practice Address - Street 1:360 STATION DR
Practice Address - Street 2:SUITE 250
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7978
Practice Address - Country:US
Practice Address - Phone:815-356-1750
Practice Address - Fax:815-356-1755
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13635225100000X
IL070013810225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1619980OtherBCBS OF IL
IL367885100OtherUS DEPT OF LABOR
IL1623066OtherBCBS PROVIDER NUMBER
ILCJ4383Medicare ID - Type UnspecifiedRAILROAD MEDICARE GRP
ILK53069Medicare PIN
ILK53059Medicare PIN
IL567700Medicare PIN
IL568080Medicare PIN
IL1623066OtherBCBS PROVIDER NUMBER
ILK06557Medicare PIN
IL568150Medicare PIN
IL1619980OtherBCBS OF IL
IL367885100OtherUS DEPT OF LABOR
ILP00242089Medicare PIN