Provider Demographics
NPI:1538436084
Name:MOZDZEN, KAREN (PTA)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:MOZDZEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4641 PULASKI AVE
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:IL
Mailing Address - Zip Code:60534-2206
Mailing Address - Country:US
Mailing Address - Phone:708-642-2998
Mailing Address - Fax:
Practice Address - Street 1:4735 WILLOW SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-6130
Practice Address - Country:US
Practice Address - Phone:708-354-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-29
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.005742225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant