Provider Demographics
NPI:1477196863
Name:MAZZA, KAITLYN
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:MAZZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 GREENVILLE BLVD SE STE B1
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-5758
Mailing Address - Country:US
Mailing Address - Phone:252-341-4192
Mailing Address - Fax:
Practice Address - Street 1:2129 S GLENBURNIE RD STE 17
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-2240
Practice Address - Country:US
Practice Address - Phone:252-341-4192
Practice Address - Fax:866-309-9297
Is Sole Proprietor?:No
Enumeration Date:2019-10-18
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-19-37119103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst