Healthcare Provider Details

I. General information

NPI: 1053283572
Provider Name (Legal Business Name): EWA MARTHA WISNIEWSKI PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2025
Last Update Date: 09/23/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 RIVERBEND DR
SPRINGFIELD OR
97477-8800
US

IV. Provider business mailing address

8717 COVENTRY DR
WOODRIDGE IL
60517-7503
US

V. Phone/Fax

Practice location:
  • Phone: 541-222-7300
  • Fax:
Mailing address:
  • Phone: 630-923-4729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.029477
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: