Provider Demographics
NPI:1831682624
Name:MAZUR, SALLY
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:MAZUR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SALLY MAZUR
Mailing Address - Street 2:34 JAMES STREET
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02465
Mailing Address - Country:US
Mailing Address - Phone:617-501-2540
Mailing Address - Fax:
Practice Address - Street 1:MEMORIAL SPAULDING SCHOOL
Practice Address - Street 2:250 BROOKLINE STREET
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02465
Practice Address - Country:US
Practice Address - Phone:617-501-2540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA583969101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA583969OtherBOARD OF SOCIAL WORK, MASSACHUSETTS