Provider Demographics
NPI:1871132829
Name:MLECZKO, KONRAD
Entity type:Individual
Prefix:
First Name:KONRAD
Middle Name:
Last Name:MLECZKO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7869 W CAHILL TER APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-3793
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 JAMESTOWN LN
Practice Address - Street 2:
Practice Address - City:LINCOLNSHIRE
Practice Address - State:IL
Practice Address - Zip Code:60069-2119
Practice Address - Country:US
Practice Address - Phone:224-543-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-22
Last Update Date:2019-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057004563224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant