Provider Demographics
NPI:1518778539
Name:WICZUK, IVANNA (LMT)
Entity type:Individual
Prefix:
First Name:IVANNA
Middle Name:
Last Name:WICZUK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3247 LANCASTER DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-4376
Mailing Address - Country:US
Mailing Address - Phone:313-903-1576
Mailing Address - Fax:
Practice Address - Street 1:6031 19 MILE RD STE A
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314-2181
Practice Address - Country:US
Practice Address - Phone:586-576-7965
Practice Address - Fax:586-510-4921
Is Sole Proprietor?:No
Enumeration Date:2025-01-17
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501003210225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist