Provider Demographics
NPI:1457533630
Name:KIEDROWSKI, CHAD E
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:E
Last Name:KIEDROWSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10776 FREMONT ST
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-9630
Mailing Address - Country:US
Mailing Address - Phone:951-797-0114
Mailing Address - Fax:
Practice Address - Street 1:10776 FREMONT ST
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-9630
Practice Address - Country:US
Practice Address - Phone:951-797-0114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-29
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT87428106H00000X
CA451681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical