Healthcare Provider Details

I. General information

NPI: 1164520755
Provider Name (Legal Business Name): PETER PAUL MAZZELLA JR. LCSW-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N. 5TH ST, MHS-1
HOT SPRINGS SD
57747
US

IV. Provider business mailing address

500 N. 5TH ST, MHS-1
HOT SPRINGS SD
57747
US

V. Phone/Fax

Practice location:
  • Phone: 605-745-2000
  • Fax: 605-745-2089
Mailing address:
  • Phone: 605-745-2000
  • Fax: 605-745-2089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number05643
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: