Provider Demographics
NPI:1598397150
Name:TKACZUK, CARLEY
Entity Type:Individual
Prefix:
First Name:CARLEY
Middle Name:
Last Name:TKACZUK
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 1:210 S SCHOOL LN
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603-4924
Mailing Address - Country:US
Mailing Address - Phone:570-217-3435
Mailing Address - Fax:
Practice Address - Street 1:40 DILWORTH RD
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17551
Practice Address - Country:US
Practice Address - Phone:570-217-3435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool