Provider Demographics
NPI:1871807008
Name:WALASEK, WANDA GRAZYNA
Entity type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:GRAZYNA
Last Name:WALASEK
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 1:4988 SYCAMORE DR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-6107
Mailing Address - Country:US
Mailing Address - Phone:734-557-3259
Mailing Address - Fax:734-557-3259
Practice Address - Street 1:8380 GEDDES RD
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198-9404
Practice Address - Country:US
Practice Address - Phone:734-547-7632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-29
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL1667975225200000X
IL160.002393225200000X
NY005295-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant