Provider Demographics
NPI:1992103758
Name:WACZKOWSKI, LINDA
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:WACZKOWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1646 NE EDGECLIFF CIR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4159
Mailing Address - Country:US
Mailing Address - Phone:541-728-0645
Mailing Address - Fax:541-728-0726
Practice Address - Street 1:1646 NE EDGECLIFF CIR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4159
Practice Address - Country:US
Practice Address - Phone:541-728-0465
Practice Address - Fax:541-728-0726
Is Sole Proprietor?:No
Enumeration Date:2014-12-10
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
No175T00000XOther Service ProvidersPeer Specialist