Healthcare Provider Details

I. General information

NPI: 1043685589
Provider Name (Legal Business Name): MS. AGNIESZKA ALINA WYSOCKA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2015
Last Update Date: 12/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4419 W NORTH AVE
MELROSE PARK IL
60160-1021
US

IV. Provider business mailing address

2010 HASSELL RD APT #201
HOFFMAN ESTATES IL
60169-6340
US

V. Phone/Fax

Practice location:
  • Phone: 773-777-7112
  • Fax: 708-547-7732
Mailing address:
  • Phone: 847-922-2210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180005556
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: