Healthcare Provider Details

I. General information

NPI: 1124593959
Provider Name (Legal Business Name): MELISSA CATHERINE IWANICKI PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2018
Last Update Date: 10/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 MILLER DR
NORTH AURORA IL
60542-5143
US

IV. Provider business mailing address

66 MILLER DR STE 102
NORTH AURORA IL
60542-5144
US

V. Phone/Fax

Practice location:
  • Phone: 630-907-9165
  • Fax:
Mailing address:
  • Phone: 630-907-9165
  • Fax: 630-907-9195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number070.011765
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: