Provider Demographics
NPI:1215057104
Name:MAZELLA, KIMBERLY BROOKS (MS)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:BROOKS
Last Name:MAZELLA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:MILES
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:6723 WHITTIER AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-4544
Mailing Address - Country:US
Mailing Address - Phone:703-538-2499
Mailing Address - Fax:866-257-9009
Practice Address - Street 1:6723 WHITTIER AVE STE 206
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-4544
Practice Address - Country:US
Practice Address - Phone:703-538-2499
Practice Address - Fax:866-257-9009
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701004147101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional