Provider Demographics
NPI:1720073331
Name:WILCZEWSKI, LAURA BETH (PT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:BETH
Last Name:WILCZEWSKI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:799 CONCORD AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-1048
Mailing Address - Country:US
Mailing Address - Phone:617-864-4200
Mailing Address - Fax:617-491-7368
Practice Address - Street 1:799 CONCORD AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-1048
Practice Address - Country:US
Practice Address - Phone:617-864-4200
Practice Address - Fax:617-491-7368
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-20
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8255225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Y66795OtherBCBS
MA0396851Medicaid
Y66795OtherBCBS