Basic Information
| Provider Information | |||||||||
| NPI: | 1710172481 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BACZKIEWICZ | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | |||||||||
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| Credential: | LGSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4855 W ARROWHEAD RD | ||||||||
| Address2: | ESSENTIA HEALTH HERMANTOWN CLINIC | ||||||||
| City: | HERMANTOWN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558113936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187863540 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4855 W ARROWHEAD RD | ||||||||
| Address2: | ESSENTIA HEALTH HERMANTOWN CLINIC | ||||||||
| City: | HERMANTOWN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558113936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187863540 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2007 | ||||||||
| LastUpdateDate: | 01/09/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 17454 | MN | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.