Provider Demographics
NPI:1245236819
Name:CHMIELEWSKI, CHARLES J (PHD, LP)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:CHMIELEWSKI
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1526 30TH ST NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-4133
Mailing Address - Country:US
Mailing Address - Phone:218-751-0887
Mailing Address - Fax:
Practice Address - Street 1:1526 30TH ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-4133
Practice Address - Country:US
Practice Address - Phone:218-751-0887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1921103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN373748900Medicaid
MN1245236819Medicare PIN
MNR04949Medicare UPIN