Healthcare Provider Details

I. General information

NPI: 1811723778
Provider Name (Legal Business Name): BREE WYSOCKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2024
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROOSEVELT RD STE 308
GLEN ELLYN IL
60137-5839
US

IV. Provider business mailing address

560 SPRUCE DR
NAPERVILLE IL
60540-7233
US

V. Phone/Fax

Practice location:
  • Phone: 630-796-0884
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150.114091
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: