Healthcare Provider Details

I. General information

NPI: 1487151627
Provider Name (Legal Business Name): BRANDON MAZZOLA OTRL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 04/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

823 W MICHIGAN AVE
MARSHALL MI
49068-1445
US

IV. Provider business mailing address

600 OAKMONT LN STE 600C
WESTMONT IL
60559-5548
US

V. Phone/Fax

Practice location:
  • Phone: 269-248-4300
  • Fax: 269-781-5505
Mailing address:
  • Phone: 630-575-6200
  • Fax: 630-928-5080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201010163
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: