Healthcare Provider Details

I. General information

NPI: 1417161464
Provider Name (Legal Business Name): COLLEEN MARIE MAZZA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 08/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 HOOVER ST
NEW HOLSTEIN WI
53061-1636
US

IV. Provider business mailing address

2303 S 15TH ST
SHEBOYGAN WI
53081-6240
US

V. Phone/Fax

Practice location:
  • Phone: 920-898-5627
  • Fax:
Mailing address:
  • Phone: 920-457-6580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3424-024
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number3424-024
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number3424-024
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: