Provider Demographics
NPI:1558630079
Name:MACIEJ, REBECCA ANN (LICSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
Last Name:MACIEJ
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:ANN
Other - Last Name:MICEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:1053 KEEFE ST
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-1410
Mailing Address - Country:US
Mailing Address - Phone:651-645-4439
Mailing Address - Fax:
Practice Address - Street 1:317 YORK AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-4039
Practice Address - Country:US
Practice Address - Phone:651-774-0011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN185321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical