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General NPI Number Information
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NPI Number | 1194932251
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Entity Type | Individual
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Provider Name | GWEN ELLEN MARTONE MAZZA LMHC
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Gender | Female
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Dates
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Enumeration Date | 05/17/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2024 W HENRIETTA RD SUITE 3-F
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City | ROCHESTER
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State | NY
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Zip | 14623-1355
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Country | US
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Telephone | 585-713-5544
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Fax | 585-723-5544
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Provider Business Mailing Address
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Address Line | 34 KIRKGATE DR
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City | SPENCERPORT
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State | NY
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Zip | 14559-2124
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Country | US
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Telephone | 585-349-2280
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Fax | 585-723-5544
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 0001115-1
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License Number State | NY
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