Provider Demographics
NPI:1356768071
Name:MACIEJEWSKI, SARA
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:MACIEJEWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W274S8375 BEAVER TRL
Mailing Address - Street 2:
Mailing Address - City:MUKWONAGO
Mailing Address - State:WI
Mailing Address - Zip Code:53149-9692
Mailing Address - Country:US
Mailing Address - Phone:262-352-3889
Mailing Address - Fax:
Practice Address - Street 1:316 N MILWAUKEE ST
Practice Address - Street 2:SUITE 208
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-5885
Practice Address - Country:US
Practice Address - Phone:414-615-0665
Practice Address - Fax:414-615-0667
Is Sole Proprietor?:No
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0487-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant