Healthcare Provider Details

I. General information

NPI: 1083071997
Provider Name (Legal Business Name): BEATA KOSYCARZ PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2016
Last Update Date: 01/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5831 N NORTHWEST HWY
CHICAGO IL
60631-2642
US

IV. Provider business mailing address

5831 N NORTHWEST HWY
CHICAGO IL
60631-2642
US

V. Phone/Fax

Practice location:
  • Phone: 773-775-8080
  • Fax: 773-775-9672
Mailing address:
  • Phone: 773-775-8080
  • Fax: 773-775-9672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160.001677
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: