Provider Demographics
NPI:1205446614
Name:MAZZOLA, TRYSHA RENAE-MYCHELLE (LCSWA)
Entity type:Individual
Prefix:MS
First Name:TRYSHA
Middle Name:RENAE-MYCHELLE
Last Name:MAZZOLA
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 MERCHANTS CT
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-7439
Mailing Address - Country:US
Mailing Address - Phone:919-904-8945
Mailing Address - Fax:
Practice Address - Street 1:909 MERCHANTS CT
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-7439
Practice Address - Country:US
Practice Address - Phone:919-904-8945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-01
Last Update Date:2021-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0142901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty