Provider Demographics
NPI:1689044562
Name:WIERZBICKI, CONNIE (CASAC)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:WIERZBICKI
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 COUNTY ROUTE 37
Mailing Address - Street 2:
Mailing Address - City:CENTRAL SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:13036-2138
Mailing Address - Country:US
Mailing Address - Phone:315-601-5829
Mailing Address - Fax:
Practice Address - Street 1:526 OLD LIVERPOOL RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-6238
Practice Address - Country:US
Practice Address - Phone:315-453-3911
Practice Address - Fax:315-453-0197
Is Sole Proprietor?:No
Enumeration Date:2015-10-05
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY21900101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420800Medicaid