Provider Demographics
NPI:1659099364
Name:MAZYCK, MARLEA CAROL (LCSW)
Entity Type:Individual
Prefix:
First Name:MARLEA
Middle Name:CAROL
Last Name:MAZYCK
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 1:4637 MILLHAVEN RD
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-9330
Mailing Address - Country:US
Mailing Address - Phone:330-307-1702
Mailing Address - Fax:
Practice Address - Street 1:4637 MILLHAVEN RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-9330
Practice Address - Country:US
Practice Address - Phone:330-307-1702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0081411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical