Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 227005982 | IL |
NPI | 1003415001 |
---|---|
Provider Name | Amanda L Klimczak |
First Address | Berwyn, IL 60402-1142 |
Second Address | Berwyn, IL 60402-1142 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/10/2020 |
Last Update Date | 21/10/2020 |