Provider Demographics
NPI:1811606676
Name:BIG LAKE BEHAVIORAL, PLLC
Entity type:Organization
Organization Name:BIG LAKE BEHAVIORAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZZOLA
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:603-918-1735
Mailing Address - Street 1:PO BOX 6058
Mailing Address - Street 2:
Mailing Address - City:LACONIA
Mailing Address - State:NH
Mailing Address - Zip Code:03247-6058
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 COUNTRY CLUB RD UNIT 202
Practice Address - Street 2:
Practice Address - City:GILFORD
Practice Address - State:NH
Practice Address - Zip Code:03249-6976
Practice Address - Country:US
Practice Address - Phone:603-293-5546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-21
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHMS8119578OtherDEA