Healthcare Provider Details

I. General information

NPI: 1295003929
Provider Name (Legal Business Name): KRYSTYNA MATYSIUK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2011
Last Update Date: 12/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

539 S LINCOLN ST
ADDISON IL
60101-4418
US

IV. Provider business mailing address

539 S LINCOLN ST
ADDISON IL
60101-4418
US

V. Phone/Fax

Practice location:
  • Phone: 312-953-5602
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160005705
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: