Provider Demographics
NPI:1386702074
Name:KACZMAREK, PENELOPE O (MSW)
Entity type:Individual
Prefix:
First Name:PENELOPE
Middle Name:O
Last Name:KACZMAREK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1684 N COAST HWY
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365
Mailing Address - Country:US
Mailing Address - Phone:541-574-4050
Mailing Address - Fax:
Practice Address - Street 1:1684 N COAST HWY
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365
Practice Address - Country:US
Practice Address - Phone:541-574-4050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORJ2730OtherPACIFIC SOURCE
ORR107803Medicare ID - Type Unspecified