Healthcare Provider Details

I. General information

NPI: 1477631307
Provider Name (Legal Business Name): MAZZONI CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 09/05/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1348 BAINBRIDGE ST
PHILADELPHIA PA
19147-1810
US

IV. Provider business mailing address

1348 BAINBRIDGE ST
PHILADELPHIA PA
19147-1810
US

V. Phone/Fax

Practice location:
  • Phone: 215-563-0652
  • Fax: 215-563-0664
Mailing address:
  • Phone: 215-563-0652
  • Fax: 215-563-0664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number807382
License Number StatePA
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ALECIA MANLEY
Title or Position: COO
Credential:
Phone: 215-563-0652