Provider Demographics
NPI:1972636728
Name:MAZZOLA, SUSAN (LCSWR)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MAZZOLA
Suffix:
Gender:F
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 W END AVE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-6413
Mailing Address - Country:US
Mailing Address - Phone:516-639-1463
Mailing Address - Fax:
Practice Address - Street 1:2277 GRAND AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-3148
Practice Address - Country:US
Practice Address - Phone:516-377-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0425901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN68061Medicare ID - Type Unspecified