Provider Demographics
NPI:1134653082
Name:NIEDZWIECKI, ERIN RENEE (RBT)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:RENEE
Last Name:NIEDZWIECKI
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1561 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17702-7038
Mailing Address - Country:US
Mailing Address - Phone:570-447-3262
Mailing Address - Fax:
Practice Address - Street 1:1561 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:SOUTH WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17702-7038
Practice Address - Country:US
Practice Address - Phone:570-447-3262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA347933106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA347933OtherREGISTERED BEHAVIOR TECHNICIAN