Provider Demographics
NPI:1225426695
Name:PANASIEWICZ, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:PANASIEWICZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LANSE
Mailing Address - State:MI
Mailing Address - Zip Code:49946-1121
Mailing Address - Country:US
Mailing Address - Phone:906-231-1350
Mailing Address - Fax:
Practice Address - Street 1:409 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LANSE
Practice Address - State:MI
Practice Address - Zip Code:49946-1121
Practice Address - Country:US
Practice Address - Phone:906-231-1350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010968881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801096888OtherSTATE LICENSE