Provider Demographics
NPI:1477720134
Name:SMYCZEK, JOELLE M (PTA)
Entity type:Individual
Prefix:MS
First Name:JOELLE
Middle Name:M
Last Name:SMYCZEK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14046 W TIFFANY PL
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-4533
Mailing Address - Country:US
Mailing Address - Phone:414-467-6317
Mailing Address - Fax:
Practice Address - Street 1:14046 W TIFFANY PL
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-4533
Practice Address - Country:US
Practice Address - Phone:414-467-6317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1006-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant