Healthcare Provider Details

I. General information

NPI: 1265971592
Provider Name (Legal Business Name): AGNIESZKA KISIEL-MUCHA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2017
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4515 N MILWAUKEE AVE
CHICAGO IL
60630-3711
US

IV. Provider business mailing address

3837 N PARIS AVE
CHICAGO IL
60634-2043
US

V. Phone/Fax

Practice location:
  • Phone: 312-671-4111
  • Fax:
Mailing address:
  • Phone: 847-977-2953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.022782
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: