Provider Demographics
NPI:1215758727
Name:MAZZOLA, KEVIN (PHD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:MAZZOLA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 THORNTON RD
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02467-3611
Mailing Address - Country:US
Mailing Address - Phone:201-835-5580
Mailing Address - Fax:
Practice Address - Street 1:30 MONUMENT SQ STE 150
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-1858
Practice Address - Country:US
Practice Address - Phone:617-661-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-18
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPSY10000169103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical