Healthcare Provider Details

I. General information

NPI: 1528281896
Provider Name (Legal Business Name): CAROLE A. MAZUROWSKI, PHD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 04/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6565 AMERICAS PKWY NE SUITE 200
ALBUQUERQUE NM
87110-8116
US

IV. Provider business mailing address

PO BOX 90815
ALBUQUERQUE NM
87199-0815
US

V. Phone/Fax

Practice location:
  • Phone: 505-620-2848
  • Fax: 866-578-0586
Mailing address:
  • Phone: 505-620-2848
  • Fax: 866-578-0586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number0881
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number0881
License Number StateNM

VIII. Authorized Official

Name: DR. CAROLE A. MAZUROWSKI
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 505-620-2848