Provider Demographics
NPI:1982170890
Name:KSIAZAK, TRACY M (PHD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:M
Last Name:KSIAZAK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:937 COTTONWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52240-2110
Mailing Address - Country:US
Mailing Address - Phone:765-749-3593
Mailing Address - Fax:
Practice Address - Street 1:600 BLANK HONORS CTR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-0454
Practice Address - Country:US
Practice Address - Phone:319-335-6148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA091877103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling