Provider Demographics
NPI:1982650214
Name:GWIAZDON, ANGIE (MSE)
Entity Type:Individual
Prefix:MRS
First Name:ANGIE
Middle Name:
Last Name:GWIAZDON
Suffix:
Gender:F
Credentials:MSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 NEWTON AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55405-2042
Mailing Address - Country:US
Mailing Address - Phone:612-377-9190
Mailing Address - Fax:612-374-4498
Practice Address - Street 1:2809 WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-2131
Practice Address - Country:US
Practice Address - Phone:612-377-9190
Practice Address - Fax:612-374-4498
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1211101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health