Provider Demographics
NPI:1043685589
Name:WYSOCKA, AGNIESZKA ALINA
Entity type:Individual
Prefix:MS
First Name:AGNIESZKA
Middle Name:ALINA
Last Name:WYSOCKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 HASSELL RD
Mailing Address - Street 2:APT #201
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60169-6340
Mailing Address - Country:US
Mailing Address - Phone:847-922-2210
Mailing Address - Fax:
Practice Address - Street 1:4419 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1021
Practice Address - Country:US
Practice Address - Phone:773-777-7112
Practice Address - Fax:708-547-7732
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-09
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180005556101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional