Provider Demographics
NPI:1063577856
Name:MAZON, OWEN (LCSW-R)
Entity type:Individual
Prefix:MR
First Name:OWEN
Middle Name:
Last Name:MAZON
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 HUDSON MANOR TER APT 6P
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-1107
Mailing Address - Country:US
Mailing Address - Phone:718-796-0696
Mailing Address - Fax:
Practice Address - Street 1:3801 HUDSON MANOR TER APT 6P
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-1107
Practice Address - Country:US
Practice Address - Phone:718-796-0696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR050092-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN5M441Medicare ID - Type Unspecified