Healthcare Provider Details

I. General information

NPI: 1790724573
Provider Name (Legal Business Name): DAVID JOSEPH MAZALESKI LCAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 10/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1131-B MALCOLM BLVD.
RUTHERFORD COLLEGE NC
28671
US

IV. Provider business mailing address

PO BOX 247
RUTHERFORD COLLEGE NC
28671
US

V. Phone/Fax

Practice location:
  • Phone: 828-874-5511
  • Fax: 828-874-5511
Mailing address:
  • Phone: 828-874-5511
  • Fax: 828-874-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number380
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: