Provider Demographics
NPI:1770381402
Name:BODUCH, PATRYK (PTA)
Entity type:Individual
Prefix:
First Name:PATRYK
Middle Name:
Last Name:BODUCH
Suffix:
Gender:
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3018 FARRELL AVE
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1142
Mailing Address - Country:US
Mailing Address - Phone:773-710-3958
Mailing Address - Fax:
Practice Address - Street 1:7230 W NORTH AVE STE 212
Practice Address - Street 2:
Practice Address - City:ELMWOOD PARK
Practice Address - State:IL
Practice Address - Zip Code:60707-4213
Practice Address - Country:US
Practice Address - Phone:708-456-2322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-06
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.009081225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant