Provider Demographics
NPI:1376094888
Name:MAZAKA, KRISTAN (LICSW)
Entity Type:Individual
Prefix:
First Name:KRISTAN
Middle Name:
Last Name:MAZAKA
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 MANTER MILL RD
Mailing Address - Street 2:
Mailing Address - City:LONDONDERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03053-2394
Mailing Address - Country:US
Mailing Address - Phone:978-604-1294
Mailing Address - Fax:
Practice Address - Street 1:19 1/2 MYSTIC STREET
Practice Address - Street 2:
Practice Address - City:METHUEN
Practice Address - State:MA
Practice Address - Zip Code:01844
Practice Address - Country:US
Practice Address - Phone:978-794-8668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1186191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical