Provider Demographics
NPI:1235856519
Name:MAZZA, GINA M (LMT)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:M
Last Name:MAZZA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MRS
Other - First Name:GINA
Other - Middle Name:M
Other - Last Name:MAZZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:220 FORT SALONGA RD
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-3900
Mailing Address - Country:US
Mailing Address - Phone:917-741-0687
Mailing Address - Fax:
Practice Address - Street 1:220 FORT SALONGA RD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-3900
Practice Address - Country:US
Practice Address - Phone:917-741-0687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018362225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist