Healthcare Provider Details

I. General information

NPI: 1215620265
Provider Name (Legal Business Name): AGNIESZKA R MAZURKIEWICZ KUBOWICZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2023
Last Update Date: 05/26/2023
Certification Date: 05/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4515 N MILWAUKEE AVE
CHICAGO IL
60630-3711
US

IV. Provider business mailing address

330 WISTERIA DR
STREAMWOOD IL
60107-2213
US

V. Phone/Fax

Practice location:
  • Phone: 312-671-4111
  • Fax:
Mailing address:
  • Phone: 630-441-0435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: