Provider Demographics
NPI:1417553454
Name:GWOZDZ, BRIAN MARTIN (LADC 1)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:MARTIN
Last Name:GWOZDZ
Suffix:
Gender:M
Credentials:LADC 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 LAKESHORE RD
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-6514
Mailing Address - Country:US
Mailing Address - Phone:413-519-4237
Mailing Address - Fax:855-260-8265
Practice Address - Street 1:13 LAKESHORE RD
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-6514
Practice Address - Country:US
Practice Address - Phone:413-519-4237
Practice Address - Fax:855-260-8265
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1535101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty