Provider Demographics
NPI:1477631307
Name:MAZZONI CENTER
Entity Type:Organization
Organization Name:MAZZONI CENTER
Other - Org Name:PCHA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:ALECIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-563-0652
Mailing Address - Street 1:1348 BAINBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-1810
Mailing Address - Country:US
Mailing Address - Phone:215-563-0652
Mailing Address - Fax:215-563-0664
Practice Address - Street 1:1348 BAINBRIDGE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-1810
Practice Address - Country:US
Practice Address - Phone:215-563-0652
Practice Address - Fax:215-563-0664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 104100000X, 207Q00000X, 251B00000X
PA807382251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007555740014Medicaid
PA1007555740014Medicaid