Provider Demographics
NPI:1174891592
Name:MAZDA, TERESA
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:MAZDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 RUSSELL RD
Mailing Address - Street 2:
Mailing Address - City:PAOLI
Mailing Address - State:PA
Mailing Address - Zip Code:19301-1236
Mailing Address - Country:US
Mailing Address - Phone:610-644-6464
Mailing Address - Fax:
Practice Address - Street 1:871 BALTIMORE PIKE
Practice Address - Street 2:UNIT 32
Practice Address - City:GLEN MILLS
Practice Address - State:PA
Practice Address - Zip Code:19342
Practice Address - Country:US
Practice Address - Phone:610-644-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0170731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical