Provider Demographics
NPI:1497565212
Name:MAZZOTTA, PETER
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:MAZZOTTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 SAN CARLOS AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:CA
Mailing Address - Zip Code:94706-1822
Mailing Address - Country:US
Mailing Address - Phone:510-387-3501
Mailing Address - Fax:
Practice Address - Street 1:1050 HOBBIT ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-1960
Practice Address - Country:US
Practice Address - Phone:510-387-3501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-13
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician