Provider Demographics
NPI:1841235090
Name:TOMCZAK, STACEY MELISSA (DPT)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:MELISSA
Last Name:TOMCZAK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:MELISSA
Other - Last Name:CROCCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:205 W WACKER DR
Mailing Address - Street 2:SUITE 1020
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-1216
Mailing Address - Country:US
Mailing Address - Phone:312-640-0329
Mailing Address - Fax:
Practice Address - Street 1:1156 W LAKE COOK RD
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-1979
Practice Address - Country:US
Practice Address - Phone:847-498-1886
Practice Address - Fax:847-520-7290
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-013869225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
IL$$$$$$$$$001Medicaid
ILP00337052Medicare PIN
ILK25956Medicare ID - Type Unspecified