Provider Demographics
NPI:1306971957
Name:MAZZELLO, PATRICIA SUSAN (LMSW ACSW LMFT)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:SUSAN
Last Name:MAZZELLO
Suffix:
Gender:F
Credentials:LMSW ACSW LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 PORTAGE RD
Mailing Address - Street 2:STE 106
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001
Mailing Address - Country:US
Mailing Address - Phone:269-345-5041
Mailing Address - Fax:
Practice Address - Street 1:4000 PORTAGE RD
Practice Address - Street 2:STE 106
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49001
Practice Address - Country:US
Practice Address - Phone:269-345-5041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILMSW6801012420104100000X
MILMFT4101005696106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M32080Medicare ID - Type Unspecified