Provider Demographics
NPI:1184634354
Name:NIEWIADOMSKI, MICHAEL (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:NIEWIADOMSKI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 LATROBE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-4851
Mailing Address - Country:US
Mailing Address - Phone:704-362-2663
Mailing Address - Fax:704-362-2836
Practice Address - Street 1:3303 LATROBE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-4851
Practice Address - Country:US
Practice Address - Phone:704-362-2663
Practice Address - Fax:704-362-2836
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1003103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2810270BMedicare ID - Type Unspecified