Healthcare Provider Details

I. General information

NPI: 1700211695
Provider Name (Legal Business Name): KELLY R ROSZCZYBIUK DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2013
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 WAUKEGAN RD
DEERFIELD IL
60015-5652
US

IV. Provider business mailing address

1517 LAKE AVE
WILMETTE IL
60091-1637
US

V. Phone/Fax

Practice location:
  • Phone: 872-201-8527
  • Fax:
Mailing address:
  • Phone: 815-735-4337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070-020245
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: