Healthcare Provider Details

I. General information

NPI: 1922004761
Provider Name (Legal Business Name): SHELLEY A. MAZZIE MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 09/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9848 NORTH TRYON STREET
CHARLOTTE NC
28262
US

IV. Provider business mailing address

4601 PARK RD SUITE 300
CHARLOTTE NC
28209-3239
US

V. Phone/Fax

Practice location:
  • Phone: 704-323-2000
  • Fax:
Mailing address:
  • Phone: 704-323-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number001799
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number12370
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: