Provider Demographics
NPI:1912368507
Name:MAZZOLA, MARY KATHRYN (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:MAZZOLA
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 1:741 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-4206
Mailing Address - Country:US
Mailing Address - Phone:336-703-3770
Mailing Address - Fax:336-748-3100
Practice Address - Street 1:741 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-4206
Practice Address - Country:US
Practice Address - Phone:336-703-3770
Practice Address - Fax:336-748-3100
Is Sole Proprietor?:No
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0033101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical