Provider Demographics
NPI:1609400084
Name:DIMARZO, KASONDRA MAE
Entity Type:Individual
Prefix:PROF
First Name:KASONDRA
Middle Name:MAE
Last Name:DIMARZO
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:PO BOX 354
Mailing Address - Street 2:
Mailing Address - City:FAITH
Mailing Address - State:NC
Mailing Address - Zip Code:28041-0354
Mailing Address - Country:US
Mailing Address - Phone:704-724-9444
Mailing Address - Fax:
Practice Address - Street 1:1401 E 7TH ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-6300
Practice Address - Country:US
Practice Address - Phone:704-612-6537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician