Provider Demographics
NPI:1841204989
Name:STAWARZ, BRIAN (MA, LP, LMFT)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:STAWARZ
Suffix:
Gender:M
Credentials:MA, LP, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 EUSTIS ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-1219
Mailing Address - Country:US
Mailing Address - Phone:651-646-6393
Mailing Address - Fax:651-255-2380
Practice Address - Street 1:2230 COMO AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-1720
Practice Address - Country:US
Practice Address - Phone:651-635-0095
Practice Address - Fax:651-635-0454
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0136106H00000X
MN2908103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN748250700Medicaid