Healthcare Provider Details

I. General information

NPI: 1154967586
Provider Name (Legal Business Name): MARY ZIELIE MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2019
Last Update Date: 03/13/2020
Certification Date: 03/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

733 2ND AVENUE
KOTZEBUE AK
99752
US

IV. Provider business mailing address

PO BOX 256
KOTZEBUE AK
99752-0256
US

V. Phone/Fax

Practice location:
  • Phone: 907-442-7640
  • Fax:
Mailing address:
  • Phone: 907-442-7640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: