Healthcare Provider Details

I. General information

NPI: 1932103348
Provider Name (Legal Business Name): MICHELLE KUJAWA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 11/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 E HANOVER ST
NEW BADEN IL
62265-1811
US

IV. Provider business mailing address

2810 FRANK SCOTT PKWY W SUITE 824
BELLEVILLE IL
62223-5007
US

V. Phone/Fax

Practice location:
  • Phone: 618-588-4000
  • Fax: 618-588-4800
Mailing address:
  • Phone: 618-234-9705
  • Fax: 618-257-0665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11-03291
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.015449
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: