Healthcare Provider Details

I. General information

NPI: 1003513375
Provider Name (Legal Business Name): MARY BUZZETTA PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY E BELSOM

II. Dates (important events)

Enumeration Date: 02/07/2023
Last Update Date: 09/27/2023
Certification Date: 09/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5788 ECKHERT RD
SAN ANTONIO TX
78240-3900
US

IV. Provider business mailing address

5788 ECKHERT RD
SAN ANTONIO TX
78240-3900
US

V. Phone/Fax

Practice location:
  • Phone: 210-450-7222
  • Fax:
Mailing address:
  • Phone: 210-450-7222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number67230
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number37981
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: