Provider Demographics
NPI:1093591323
Name:MAZZOLA, CASEY
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:MAZZOLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 BROOK HILL LN APT B
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14625-2236
Mailing Address - Country:US
Mailing Address - Phone:585-698-5518
Mailing Address - Fax:
Practice Address - Street 1:37 BROOK HILL LN APT B
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14625-2236
Practice Address - Country:US
Practice Address - Phone:585-698-5518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-04
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002796103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst