Provider Demographics
NPI:1629756606
Name:MAZICK, CHARLES MATTHEW (LGPC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MATTHEW
Last Name:MAZICK
Suffix:
Gender:M
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8894 STANFORD BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-4794
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:347-903-6927
Practice Address - Street 1:8894 STANFORD BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-4794
Practice Address - Country:US
Practice Address - Phone:443-718-0059
Practice Address - Fax:347-903-6927
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP13378101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health