Healthcare Provider Details

I. General information

NPI: 1982170890
Provider Name (Legal Business Name): TRACY M KSIAZAK PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2018
Last Update Date: 10/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 BLANK HONORS CTR
IOWA CITY IA
52242-0454
US

IV. Provider business mailing address

937 COTTONWOOD AVE
IOWA CITY IA
52240-2110
US

V. Phone/Fax

Practice location:
  • Phone: 319-335-6148
  • Fax:
Mailing address:
  • Phone: 765-749-3593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number091877
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: