Provider Demographics
NPI:1457520033
Name:WISNIEWSKI, SUSAN MARY (OTR)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARY
Last Name:WISNIEWSKI
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8785 SONOMA TRL
Mailing Address - Street 2:
Mailing Address - City:SPRING GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60081-8255
Mailing Address - Country:US
Mailing Address - Phone:815-349-0225
Mailing Address - Fax:
Practice Address - Street 1:708 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-2265
Practice Address - Country:US
Practice Address - Phone:815-338-1707
Practice Address - Fax:815-338-1786
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05615103OtherBLUE CROSS BLUE SHIELD
IL362264411001Medicaid
IL147296Medicare Oscar/Certification