Provider Demographics
NPI:1548595796
Name:GAZARKIEWICZ, JOSEPH F (PSYD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:F
Last Name:GAZARKIEWICZ
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 S. WOODLAND AVENUE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-7170
Mailing Address - Country:US
Mailing Address - Phone:219-879-8580
Mailing Address - Fax:219-764-7025
Practice Address - Street 1:1411 S. WOODLAND AVENUE
Practice Address - Street 2:SUITE B
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-7170
Practice Address - Country:US
Practice Address - Phone:219-763-1499
Practice Address - Fax:219-764-7025
Is Sole Proprietor?:No
Enumeration Date:2009-10-06
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042249A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200958610Medicaid