Provider Demographics
NPI:1831100379
Name:FEDIACZKO, W. GORDON (LISW)
Entity Type:Individual
Prefix:
First Name:W.
Middle Name:GORDON
Last Name:FEDIACZKO
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OH
Mailing Address - Zip Code:44460-1742
Mailing Address - Country:US
Mailing Address - Phone:330-332-0153
Mailing Address - Fax:330-337-3099
Practice Address - Street 1:12680 SALEM WARREN RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OH
Practice Address - Zip Code:44460-9668
Practice Address - Country:US
Practice Address - Phone:330-337-6527
Practice Address - Fax:330-337-3099
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-00028661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FESW02682Medicare ID - Type Unspecified