Healthcare Provider Details

I. General information

NPI: 1053892752
Provider Name (Legal Business Name): STEFAN MICHAEL SKONECZKA PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2018
Last Update Date: 02/12/2023
Certification Date: 02/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 W LAKE COOK RD
BUFFALO GROVE IL
60089-2082
US

IV. Provider business mailing address

885 MARCH ST
LAKE ZURICH IL
60047-1448
US

V. Phone/Fax

Practice location:
  • Phone: 630-368-1776
  • Fax:
Mailing address:
  • Phone: 224-766-6329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP18312
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070024236
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-1846
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: