Provider Demographics
NPI:1326010596
Name:PECZALSKA, EWA X (PHD LP)
Entity Type:Individual
Prefix:
First Name:EWA
Middle Name:X
Last Name:PECZALSKA
Suffix:
Gender:F
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 1:927 CHURCHILL ST W
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6605
Mailing Address - Country:US
Mailing Address - Phone:651-430-8537
Mailing Address - Fax:651-430-4646
Practice Address - Street 1:1500 CURVE CREST BLVD W
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6040
Practice Address - Country:US
Practice Address - Phone:651-439-1234
Practice Address - Fax:651-351-0827
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1995103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43728300Medicaid