Provider Demographics
NPI:1861983181
Name:GIZOWSKI, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:GIZOWSKI
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 1:52 W REDHEAD CT
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE BEACH
Mailing Address - State:IL
Mailing Address - Zip Code:60073-4946
Mailing Address - Country:US
Mailing Address - Phone:847-494-3642
Mailing Address - Fax:
Practice Address - Street 1:2400 N SHEFFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-3936
Practice Address - Country:US
Practice Address - Phone:312-362-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer