Provider Demographics
NPI:1710581046
Name:MAZYCK, KERISTEN (LISW-CP)
Entity Type:Individual
Prefix:
First Name:KERISTEN
Middle Name:
Last Name:MAZYCK
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1632 WAYAH DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5829
Mailing Address - Country:US
Mailing Address - Phone:843-813-2957
Mailing Address - Fax:
Practice Address - Street 1:1632 WAYAH DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5829
Practice Address - Country:US
Practice Address - Phone:843-813-2957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-27
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC91651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical