Provider Demographics
NPI:1871340422
Name:CIESIELSKI, VICKI ANN
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:ANN
Last Name:CIESIELSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VICKI
Other - Middle Name:ANN
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1647 SHEFFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-1557
Mailing Address - Country:US
Mailing Address - Phone:708-846-6713
Mailing Address - Fax:
Practice Address - Street 1:503 OTIS BOWEN DR
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-4158
Practice Address - Country:US
Practice Address - Phone:219-934-0590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-01
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06005180A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant