Provider Demographics
NPI:1891994364
Name:MAZAK, MICHAEL S (OTR)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:MAZAK
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1086
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44096-1086
Mailing Address - Country:US
Mailing Address - Phone:216-645-7242
Mailing Address - Fax:
Practice Address - Street 1:2291 W 4TH ST
Practice Address - Street 2:SUITE D
Practice Address - City:ONTARIO
Practice Address - State:OH
Practice Address - Zip Code:44906-1261
Practice Address - Country:US
Practice Address - Phone:419-589-2238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-16
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT-5497225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist