Provider Demographics
NPI:1265506851
Name:BASZCZUK, PATRICIA (PHD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:BASZCZUK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 IRON BRIDGE RD
Mailing Address - Street 2:6
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-5304
Mailing Address - Country:US
Mailing Address - Phone:732-761-2997
Mailing Address - Fax:
Practice Address - Street 1:347 HOSPITAL ROAD
Practice Address - Street 2:
Practice Address - City:ALLENWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08720
Practice Address - Country:US
Practice Address - Phone:732-938-5250
Practice Address - Fax:732-919-0538
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00422700103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0067873Medicaid
NJ0067873Medicaid