Provider Demographics
NPI:1518933779
Name:MAZICK, BRADLEY S (PHD,HSPP)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:S
Last Name:MAZICK
Suffix:
Gender:M
Credentials:PHD,HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 RIDGEDALE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-2243
Mailing Address - Country:US
Mailing Address - Phone:574-231-8000
Mailing Address - Fax:574-231-8013
Practice Address - Street 1:1920 RIDGEDALE RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-2243
Practice Address - Country:US
Practice Address - Phone:574-231-8000
Practice Address - Fax:574-231-8013
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041080103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200200720AMedicaid
IN200200720AMedicaid