Provider Demographics
NPI:1609026277
Name:KAZMIERCZAK, AUDREY (MA, LAC, LPCC, MAC)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:KAZMIERCZAK
Suffix:
Gender:F
Credentials:MA, LAC, LPCC, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 EAST ROSSER AVENUE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:BISMARK
Mailing Address - State:ND
Mailing Address - Zip Code:58301-4046
Mailing Address - Country:US
Mailing Address - Phone:701-471-1170
Mailing Address - Fax:
Practice Address - Street 1:418 EAST ROSSER AVENUE
Practice Address - Street 2:SUITE 304
Practice Address - City:BISMARK
Practice Address - State:ND
Practice Address - Zip Code:58301-4046
Practice Address - Country:US
Practice Address - Phone:701-471-1170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-19
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDLAC1243101YA0400X
NDLPCC93-7-1-91-65101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND22619OtherBCBS
ND21792OtherBCBS