Provider Demographics
NPI:1730711482
Name:KSIAZKIEWICZ, ROBERT JOHN MARK (LPC CDCA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOHN MARK
Last Name:KSIAZKIEWICZ
Suffix:
Gender:M
Credentials:LPC CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2065 STONERIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CIRCLEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43113-8956
Mailing Address - Country:US
Mailing Address - Phone:740-500-1391
Mailing Address - Fax:
Practice Address - Street 1:2065 STONERIDGE DR
Practice Address - Street 2:
Practice Address - City:CIRCLEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43113-8956
Practice Address - Country:US
Practice Address - Phone:740-500-1391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-11
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA172211101YA0400X
OHC2002535101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)