Provider Demographics
NPI:1295165173
Name:KAZMIERCZAK, SUSAN (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:KAZMIERCZAK
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 SCOTTSDALE DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-4159
Mailing Address - Country:US
Mailing Address - Phone:217-373-2436
Mailing Address - Fax:
Practice Address - Street 1:801 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3055
Practice Address - Country:US
Practice Address - Phone:217-373-2436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-14
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490158011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical