Provider Demographics
NPI:1417733031
Name:RADZIEWICZ, BRANDON
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:RADZIEWICZ
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 1:205 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MINERSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17954-1103
Mailing Address - Country:US
Mailing Address - Phone:570-691-6945
Mailing Address - Fax:
Practice Address - Street 1:1 S 2ND ST
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3174
Practice Address - Country:US
Practice Address - Phone:570-628-6990
Practice Address - Fax:570-628-5899
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC015965101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional