Provider Demographics
NPI:1740504729
Name:KREJCAREK, MOLLY (PTA)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:KREJCAREK
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 1:1095 YUREK RD
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:WI
Mailing Address - Zip Code:54162-9653
Mailing Address - Country:US
Mailing Address - Phone:715-923-8717
Mailing Address - Fax:
Practice Address - Street 1:845 S MAIN ST STE 120
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-6116
Practice Address - Country:US
Practice Address - Phone:920-322-0447
Practice Address - Fax:920-322-1362
Is Sole Proprietor?:No
Enumeration Date:2010-03-20
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI149619225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant