Provider Demographics
NPI:1548536030
Name:PAWLICZEK, DIANE MARICE (PT)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:MARICE
Last Name:PAWLICZEK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 FOURWING CT
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-8927
Mailing Address - Country:US
Mailing Address - Phone:505-977-8871
Mailing Address - Fax:505-792-2836
Practice Address - Street 1:75 FOURWING CT
Practice Address - Street 2:
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048-8927
Practice Address - Country:US
Practice Address - Phone:505-977-8871
Practice Address - Fax:505-792-2836
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2804225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist