Provider Demographics
NPI:1558017285
Name:DZIEDZIC, KARA
Entity Type:Individual
Prefix:
First Name:KARA
Middle Name:
Last Name:DZIEDZIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1109
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-7109
Mailing Address - Country:US
Mailing Address - Phone:815-756-4875
Mailing Address - Fax:815-756-2944
Practice Address - Street 1:631 S 1ST ST
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-4117
Practice Address - Country:US
Practice Address - Phone:815-756-4875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL474579189001Medicaid