Provider Demographics
NPI:1912942103
Name:WIERZCHON-MROZ, ELZBIETA (PT)
Entity Type:Individual
Prefix:MRS
First Name:ELZBIETA
Middle Name:
Last Name:WIERZCHON-MROZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:ELZBIETA
Other - Middle Name:
Other - Last Name:WIERZCHON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1225 GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-1643
Mailing Address - Country:US
Mailing Address - Phone:847-251-9790
Mailing Address - Fax:847-251-9792
Practice Address - Street 1:1225 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-1643
Practice Address - Country:US
Practice Address - Phone:847-251-9790
Practice Address - Fax:847-251-9792
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-007485225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK33026Medicare ID - Type UnspecifiedMEMBER#