Provider Demographics
NPI:1396569000
Name:IWANICKI, AUBREY W (PSYD, LP)
Entity type:Individual
Prefix:
First Name:AUBREY
Middle Name:W
Last Name:IWANICKI
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 FREEMAN DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETER
Mailing Address - State:MN
Mailing Address - Zip Code:56082-3504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 FREEMAN DR
Practice Address - Street 2:
Practice Address - City:SAINT PETER
Practice Address - State:MN
Practice Address - Zip Code:56082-3504
Practice Address - Country:US
Practice Address - Phone:507-985-2751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-09
Last Update Date:2024-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TF0200X
MNLP7097103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic