Provider Demographics
NPI:1447888946
Name:NIEZGODA, MARK J (LICSW)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:J
Last Name:NIEZGODA
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4219 S OTHELLO ST APT 517
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118-3886
Mailing Address - Country:US
Mailing Address - Phone:206-321-3997
Mailing Address - Fax:
Practice Address - Street 1:4219 S OTHELLO ST APT 517
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118-3886
Practice Address - Country:US
Practice Address - Phone:206-321-3997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-30
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW609917921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical