Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | A14156 | NC |
NPI | 1003432766 |
---|---|
Provider Name | Madison Mazza |
First Address | Clarksburg, WV 26301-5659 |
Second Address | Clarksburg, WV 26301-5659 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/06/2020 |
Last Update Date | 18/06/2020 |