Provider Demographics
NPI:1528281896
Name:CAROLE A. MAZUROWSKI, PHD, PA
Entity type:Organization
Organization Name:CAROLE A. MAZUROWSKI, PHD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MAZUROWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:505-620-2848
Mailing Address - Street 1:PO BOX 90815
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87199-0815
Mailing Address - Country:US
Mailing Address - Phone:505-620-2848
Mailing Address - Fax:866-578-0586
Practice Address - Street 1:6565 AMERICAS PKWY NE
Practice Address - Street 2:SUITE 200
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-8116
Practice Address - Country:US
Practice Address - Phone:505-620-2848
Practice Address - Fax:866-578-0586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0881103TB0200X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM300521078Medicare ID - Type UnspecifiedGROUP PROVIDER NUJMBER