Provider Demographics
NPI:1023450095
Name:BACZWASKI, BRANDY (MA)
Entity type:Individual
Prefix:MRS
First Name:BRANDY
Middle Name:
Last Name:BACZWASKI
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MO
Mailing Address - Zip Code:65251-1753
Mailing Address - Country:US
Mailing Address - Phone:573-592-2623
Mailing Address - Fax:
Practice Address - Street 1:152 HIGHWAY 7 SOUTH
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655
Practice Address - Country:US
Practice Address - Phone:662-234-7521
Practice Address - Fax:662-236-3071
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-19
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016008720103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical