Provider Demographics
NPI:1407128473
Name:MAZZARESE, KRISTIN NICOLE (LPC)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:NICOLE
Last Name:MAZZARESE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3460 BOX ELDER
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-7841
Mailing Address - Country:US
Mailing Address - Phone:443-204-2017
Mailing Address - Fax:
Practice Address - Street 1:30772 SOUTHVIEW DR
Practice Address - Street 2:SUITE 120
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-2213
Practice Address - Country:US
Practice Address - Phone:303-670-3931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-06
Last Update Date:2017-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC0012257101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health