Provider Demographics
NPI:1174698690
Name:MAZIKOWSKI, LAURA (LCPC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MAZIKOWSKI
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 FREE ST STE 402
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-3900
Mailing Address - Country:US
Mailing Address - Phone:207-772-0050
Mailing Address - Fax:
Practice Address - Street 1:22 FREE ST STE 402
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-3900
Practice Address - Country:US
Practice Address - Phone:207-772-0050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL2945101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432107699Medicaid