MEDICARE: IVANNA WICZUK LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	7501003210	MI

General Provider Information

NPI Number	:	1518778539
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IVANNA WICZUK LMT

Provider Business Mailing Address
First Line	:	3247 LANCASTER DR
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48310-4376
Country	:	US
Telephone Number	:	313-903-1576
Fax Number	:

Provider Business Practice Location Address
First Line	:	6031 19 MILE RD STE A
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48314-2181
Country	:	US
Telephone Number	:	586-576-7965
Fax Number	:	586-510-4921

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/17/2025
Last Update Date	:	01/17/2025

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