Provider Demographics
NPI:1487687638
Name:MAZUROVA, ELLA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ELLA
Middle Name:
Last Name:MAZUROVA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-2225
Mailing Address - Country:US
Mailing Address - Phone:718-966-1738
Mailing Address - Fax:
Practice Address - Street 1:3923 LAUREL AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-1136
Practice Address - Country:US
Practice Address - Phone:718-975-0707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0733621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN5U301Medicare ID - Type UnspecifiedLCSW