Basic Information
| Provider Information | |||||||||
| NPI: | 1023450095 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BACZWASKI | ||||||||
| FirstName: | BRANDY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 E 5TH ST | ||||||||
| Address2: | |||||||||
| City: | FULTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652511753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5735922623 | ||||||||
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| Practice Location | |||||||||
| Address1: | 152 HIGHWAY 7 SOUTH | ||||||||
| Address2: | |||||||||
| City: | OXFORD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 38655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622347521 | ||||||||
| FaxNumber: | 6622363071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2013 | ||||||||
| LastUpdateDate: | 08/22/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 2016008720 | MO | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.