Provider Demographics
NPI:1508070319
Name:KACZOR, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:KACZOR
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 1:41 BARRY LN
Mailing Address - Street 2:
Mailing Address - City:SIMSBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06070-2018
Mailing Address - Country:US
Mailing Address - Phone:860-331-9737
Mailing Address - Fax:
Practice Address - Street 1:1233 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-5381
Practice Address - Country:US
Practice Address - Phone:413-493-2736
Practice Address - Fax:413-493-2853
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MA2170081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health