Provider Demographics
NPI:1699198408
Name:MAZURIK-CHARLES, REBECCA (MSED)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:
Last Name:MAZURIK-CHARLES
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 N FRONT ST APT 2
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:PA
Mailing Address - Zip Code:17847-9648
Mailing Address - Country:US
Mailing Address - Phone:570-556-6954
Mailing Address - Fax:
Practice Address - Street 1:1220 N FRONT ST APT 2
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:PA
Practice Address - Zip Code:17847-9648
Practice Address - Country:US
Practice Address - Phone:570-556-6954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-29
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA09620562174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist