Provider Demographics
NPI:1295259596
Name:PANGRAZZI, CODY A (LPSW)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:A
Last Name:PANGRAZZI
Suffix:
Gender:M
Credentials:LPSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4061 OLD PESHTIGO RD
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-3887
Mailing Address - Country:US
Mailing Address - Phone:715-732-8000
Mailing Address - Fax:
Practice Address - Street 1:4061 OLD PESHTIGO RD
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-3887
Practice Address - Country:US
Practice Address - Phone:715-732-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-28
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI130736104100000X
WI92041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100069692Medicaid