Provider Demographics
NPI:1457360877
Name:MAZZOLA, MARY PAT (PSYCHOLOGIST-MA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:PAT
Last Name:MAZZOLA
Suffix:
Gender:F
Credentials:PSYCHOLOGIST-MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 MONUMENT AVE
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-2133
Mailing Address - Country:US
Mailing Address - Phone:802-688-6262
Mailing Address - Fax:
Practice Address - Street 1:185 NORTH ST
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-1813
Practice Address - Country:US
Practice Address - Phone:802-688-6262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT047-0000645103T00000X, 103TA0700X, 103TB0200X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT59034OtherBLUE CROSS
VT1007784Medicaid
VT2070654OtherCIGNA
VT360032OtherMANAGED HEALTH NET