Provider Demographics
NPI:1932603743
Name:MAZANOWSKI, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MAZANOWSKI
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 1:320 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:STEUBENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43952-2153
Mailing Address - Country:US
Mailing Address - Phone:740-314-5339
Mailing Address - Fax:740-314-5227
Practice Address - Street 1:320 MARKET ST
Practice Address - Street 2:
Practice Address - City:STEUBENVILLE
Practice Address - State:OH
Practice Address - Zip Code:43952-2153
Practice Address - Country:US
Practice Address - Phone:740-314-5339
Practice Address - Fax:740-314-5227
Is Sole Proprietor?:No
Enumeration Date:2018-03-19
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHLCDCIII.162022101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHLCDCIII.162022OtherLCDCIII