Provider Demographics
NPI:1417161464
Name:MAZZA, COLLEEN MARIE (PT)
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:MARIE
Last Name:MAZZA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2303 S 15TH ST
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-6240
Mailing Address - Country:US
Mailing Address - Phone:920-457-6580
Mailing Address - Fax:
Practice Address - Street 1:1610 HOOVER ST
Practice Address - Street 2:
Practice Address - City:NEW HOLSTEIN
Practice Address - State:WI
Practice Address - Zip Code:53061-1636
Practice Address - Country:US
Practice Address - Phone:920-898-5627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3424-024225100000X, 2251G0304X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40139600Medicaid