Healthcare Provider Details

I. General information

NPI: 1982650214
Provider Name (Legal Business Name): ANGIE GWIAZDON MSE
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2809 WAYZATA BLVD
MINNEAPOLIS MN
55405-2131
US

IV. Provider business mailing address

457 NEWTON AVE S
MINNEAPOLIS MN
55405-2042
US

V. Phone/Fax

Practice location:
  • Phone: 612-377-9190
  • Fax: 612-374-4498
Mailing address:
  • Phone: 612-377-9190
  • Fax: 612-374-4498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1211
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: