Provider Demographics
NPI:1043557408
Name:KACZMARSKI, MAUREEN AMIE ALLEN (MFCT)
Entity Type:Individual
Prefix:MRS
First Name:MAUREEN
Middle Name:AMIE ALLEN
Last Name:KACZMARSKI
Suffix:
Gender:F
Credentials:MFCT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24086 CANYON LAKE DR N
Mailing Address - Street 2:
Mailing Address - City:CANYON LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92587-8011
Mailing Address - Country:US
Mailing Address - Phone:951-907-7767
Mailing Address - Fax:
Practice Address - Street 1:24086 CANYON LAKE DR N
Practice Address - Street 2:
Practice Address - City:CANYON LAKE
Practice Address - State:CA
Practice Address - Zip Code:92587-8011
Practice Address - Country:US
Practice Address - Phone:951-907-7767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-04
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT21852106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist