Provider Demographics
NPI:1396788576
Name:MAZUR, DOROTHY E (LMSW,DCSW)
Entity type:Individual
Prefix:MRS
First Name:DOROTHY
Middle Name:E
Last Name:MAZUR
Suffix:
Gender:F
Credentials:LMSW,DCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 KENMOOR AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2390
Mailing Address - Country:US
Mailing Address - Phone:616-956-5585
Mailing Address - Fax:616-956-1940
Practice Address - Street 1:833 KENMOOR AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2390
Practice Address - Country:US
Practice Address - Phone:616-956-5585
Practice Address - Fax:616-956-1940
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI20-18255911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM16890Medicare ID - Type UnspecifiedMEDICARE
MI0M16890Medicare UPIN