Provider Demographics
NPI:1972061281
Name:MAZZULLO, DEANNA L
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:L
Last Name:MAZZULLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2233 ACADEMY PL STE 200
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-1666
Mailing Address - Country:US
Mailing Address - Phone:719-569-4411
Mailing Address - Fax:
Practice Address - Street 1:2233 ACADEMY PL STE 200
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1666
Practice Address - Country:US
Practice Address - Phone:719-569-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-05
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-19-80327106S00000X
1-24-70764103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician