Healthcare Provider Details

I. General information

NPI: 1730711482
Provider Name (Legal Business Name): ROBERT JOHN MARK KSIAZKIEWICZ LPC CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2020
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 748465
ATLANTA GA
30374-8465
US

IV. Provider business mailing address

PO BOX 748465
ATLANTA GA
30374-8465
US

V. Phone/Fax

Practice location:
  • Phone: 855-284-7483
  • Fax:
Mailing address:
  • Phone: 855-284-7483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.2404616
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.162224
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: