Healthcare Provider Details

I. General information

NPI: 1831564459
Provider Name (Legal Business Name): REBECCA CISZEK MOTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2015
Last Update Date: 12/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

192 BYRON RD
GERRARDSTOWN WV
25420-4594
US

IV. Provider business mailing address

192 BYRON RD
GERRARDSTOWN WV
25420-4594
US

V. Phone/Fax

Practice location:
  • Phone: 708-275-4752
  • Fax:
Mailing address:
  • Phone: 708-275-4752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1784
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119006509
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: