Provider Demographics
NPI:1750854741
Name:CHMIELESKI, DEBRA SUE
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:SUE
Last Name:CHMIELESKI
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 1:16383 UPPER 22ND STREET SOUTH
Mailing Address - Street 2:
Mailing Address - City:ST. CROIX BEACH
Mailing Address - State:MN
Mailing Address - Zip Code:55043
Mailing Address - Country:US
Mailing Address - Phone:651-235-0964
Mailing Address - Fax:
Practice Address - Street 1:16383 UPPER 22 ND STREET SOUTH
Practice Address - Street 2:
Practice Address - City:ST. CROIX BEACH
Practice Address - State:MN
Practice Address - Zip Code:55043
Practice Address - Country:US
Practice Address - Phone:651-235-0964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302296101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)