Healthcare Provider Details

I. General information

NPI: 1518809169
Provider Name (Legal Business Name): TARA MAZZOTTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2026
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 ALABAMA AVE SE
WASHINGTON DC
20032-4542
US

IV. Provider business mailing address

1100 ALABAMA AVE SE
WASHINGTON DC
20032-4542
US

V. Phone/Fax

Practice location:
  • Phone: 202-299-5420
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY1001423
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810005883
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number07429
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: