Basic Information
| Provider Information | |||||||||
| NPI: | 1053937516 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIONCEK | ||||||||
| FirstName: | AIDA | ||||||||
| MiddleName: | COKA | ||||||||
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| Credential: | MOT, OTR/L | ||||||||
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| OtherLastName: | COKA | ||||||||
| OtherFirstName: | AIDA | ||||||||
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| OtherCredential: | MOT, OTR/L | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9368 N LILLEY RD | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481704610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344163900 | ||||||||
| FaxNumber: | 7344532118 | ||||||||
| Practice Location | |||||||||
| Address1: | 29460 FORD RD | ||||||||
| Address2: | |||||||||
| City: | GARDEN CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481352318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7345220065 | ||||||||
| FaxNumber: | 7345220068 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2020 | ||||||||
| LastUpdateDate: | 09/22/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 5201010900 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.