Provider Demographics
NPI:1538781943
Name:WASZAK, ALISA VALE (PTA)
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:VALE
Last Name:WASZAK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 LAKE SOMMERVILLE TRL
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78633-5269
Mailing Address - Country:US
Mailing Address - Phone:219-614-7772
Mailing Address - Fax:
Practice Address - Street 1:14730 MAIN ST
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-1923
Practice Address - Country:US
Practice Address - Phone:708-333-1390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-08
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.001251225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant