Provider Demographics
NPI:1790724573
Name:MAZALESKI, DAVID JOSEPH (LCAS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JOSEPH
Last Name:MAZALESKI
Suffix:
Gender:M
Credentials:LCAS
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 247
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORD COLLEGE
Mailing Address - State:NC
Mailing Address - Zip Code:28671
Mailing Address - Country:US
Mailing Address - Phone:828-874-5511
Mailing Address - Fax:828-874-5511
Practice Address - Street 1:1131-B MALCOLM BLVD.
Practice Address - Street 2:
Practice Address - City:RUTHERFORD COLLEGE
Practice Address - State:NC
Practice Address - Zip Code:28671
Practice Address - Country:US
Practice Address - Phone:828-874-5511
Practice Address - Fax:828-874-5511
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC380101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6111754Medicaid