1295844603 NPI number — NICOLE M IWANOWSKI OTR/L, CLT

Table of content: NICOLE M IWANOWSKI OTR/L, CLT (NPI 1295844603)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295844603 NPI number — NICOLE M IWANOWSKI OTR/L, CLT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IWANOWSKI
Provider First Name:
NICOLE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR/L, CLT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GROPPI
Provider Other First Name:
NICOLE
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR/L, CLT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1295844603
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 52ND ST
Provider Second Line Business Mailing Address:
SUITE 240
Provider Business Mailing Address City Name:
KENOSHA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53140-3423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-925-5004
Provider Business Mailing Address Fax Number:
262-925-5001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10222 74TH ST
Provider Second Line Business Practice Location Address:
SUITE 211
Provider Business Practice Location Address City Name:
KENOSHA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53142-6810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-925-5020
Provider Business Practice Location Address Fax Number:
262-925-5021
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  4230026 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 11781771 . This is a "CAQH" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1295844603 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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