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General NPI Number Information
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NPI Number | 1518778539
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Entity Type | Individual
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Provider Name | IVANNA WICZUK LMT
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Gender | Female
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Dates
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Enumeration Date | 01/17/2025
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Last Update Date | 01/17/2025
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Provider Practice Location Address
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Address Line | 6031 19 MILE RD STE A
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City | STERLING HEIGHTS
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State | MI
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Zip | 48314-2181
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Country | US
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Telephone | 586-576-7965
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Fax | 586-510-4921
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Provider Business Mailing Address
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Address Line | 3247 LANCASTER DR
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City | STERLING HEIGHTS
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State | MI
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Zip | 48310-4376
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Country | US
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Telephone | 313-903-1576
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 7501003210
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License Number State | MI
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