Healthcare Provider Details

I. General information

NPI: 1811241466
Provider Name (Legal Business Name): KELLY RAFAELA DZAK PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2012
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 MADISON ST
JOLIET IL
60435-8200
US

IV. Provider business mailing address

333 MADISON STREET
JOLIET IL
60435
US

V. Phone/Fax

Practice location:
  • Phone: 815-741-7114
  • Fax:
Mailing address:
  • Phone: 815-741-7114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.013006
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: