Provider Demographics
NPI:1023574241
Name:BAWOLSKI, MARY MAGDALEN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MAGDALEN
Last Name:BAWOLSKI
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 1:4000 CUEVAS CT
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821-2865
Mailing Address - Country:US
Mailing Address - Phone:916-215-4602
Mailing Address - Fax:
Practice Address - Street 1:610 BERCUT DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95811-0115
Practice Address - Country:US
Practice Address - Phone:916-443-2479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-12
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00495830OtherKAISER