Provider Demographics
NPI:1164520755
Name:MAZZELLA, PETER PAUL JR (LCSW-C)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:PAUL
Last Name:MAZZELLA
Suffix:JR
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N. 5TH ST, MHS-1
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57747
Mailing Address - Country:US
Mailing Address - Phone:605-745-2000
Mailing Address - Fax:605-745-2089
Practice Address - Street 1:500 N. 5TH ST, MHS-1
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:SD
Practice Address - Zip Code:57747
Practice Address - Country:US
Practice Address - Phone:605-745-2000
Practice Address - Fax:605-745-2089
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD056431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical