Healthcare Provider Details

I. General information

NPI: 1326100173
Provider Name (Legal Business Name): TALITHA MAZYCK MHP, LAPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

977 TAYLOR ST SW # A
CONYERS GA
30012-5357
US

IV. Provider business mailing address

5568 STRATHMOOR MANOR CIR
LITHONIA GA
30058-2624
US

V. Phone/Fax

Practice location:
  • Phone: 770-918-6677
  • Fax:
Mailing address:
  • Phone: 404-849-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPC001480
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: