Provider Demographics
NPI:1184785685
Name:GRADZIKIEWICZ, FANNY (LPC)
Entity type:Individual
Prefix:
First Name:FANNY
Middle Name:
Last Name:GRADZIKIEWICZ
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3004 EAGLE AVE
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78504-5158
Mailing Address - Country:US
Mailing Address - Phone:956-874-2643
Mailing Address - Fax:
Practice Address - Street 1:2529 W TRENTON RD
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-5070
Practice Address - Country:US
Practice Address - Phone:956-994-3880
Practice Address - Fax:956-994-3877
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20078101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX181577101Medicaid