Provider Demographics
NPI:1063176915
Name:MAZZIOTTA, CAMERON MICHAEL (CDCA)
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:MICHAEL
Last Name:MAZZIOTTA
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 DELAWARE TRL
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:OH
Mailing Address - Zip Code:44644-9502
Mailing Address - Country:US
Mailing Address - Phone:330-771-3796
Mailing Address - Fax:
Practice Address - Street 1:3745 WHIPPLE AVE NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-4805
Practice Address - Country:US
Practice Address - Phone:330-331-7506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH176517101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)