Provider Demographics
NPI:1457994998
Name:CIECKO, DEREK JOHN (OTR)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:JOHN
Last Name:CIECKO
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1744 N FARWELL AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-1806
Mailing Address - Country:US
Mailing Address - Phone:414-225-4460
Mailing Address - Fax:414-225-4475
Practice Address - Street 1:4065 N 35TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-1705
Practice Address - Country:US
Practice Address - Phone:414-445-9180
Practice Address - Fax:414-445-5995
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI663126225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist