Provider Demographics
NPI:1952691255
Name:KIEDROWSKI, GARY ALLEN (ISP)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:ALLEN
Last Name:KIEDROWSKI
Suffix:
Gender:M
Credentials:ISP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 W GRAND AVE.
Mailing Address - Street 2:CENTRAL WISCONSIN COUNSELING SUITE 304A
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54495-2781
Mailing Address - Country:US
Mailing Address - Phone:715-424-6960
Mailing Address - Fax:715-424-6963
Practice Address - Street 1:320 W GRAND AVE.
Practice Address - Street 2:CENTRAL WISCONSIN COUNSELING SUITE 304A
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54495-2781
Practice Address - Country:US
Practice Address - Phone:715-424-6960
Practice Address - Fax:715-424-6963
Is Sole Proprietor?:No
Enumeration Date:2011-04-08
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health