Provider Demographics
NPI:1609127984
Name:MAZA, RUDYARD A (LCSW)
Entity Type:Individual
Prefix:MR
First Name:RUDYARD
Middle Name:A
Last Name:MAZA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10470 QUEENS BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-3638
Mailing Address - Country:US
Mailing Address - Phone:718-275-6010
Mailing Address - Fax:718-275-6062
Practice Address - Street 1:10470 QUEENS BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-3638
Practice Address - Country:US
Practice Address - Phone:718-275-6010
Practice Address - Fax:718-275-6062
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-26
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NY087326-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health