Healthcare Provider Details

I. General information

NPI: 1679026868
Provider Name (Legal Business Name): KELSEY L. MAZZOCCO ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2016
Last Update Date: 08/18/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 STONEY LANDING ROAD
MONCKS CORNER SC
29461-3967
US

IV. Provider business mailing address

403 STONEY LANDING ROAD
MONCKS CORNER SC
29461-3967
US

V. Phone/Fax

Practice location:
  • Phone: 864-294-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1986
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: