=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700961109
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL A MAZA LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2006
-----------------------------------------------------
Last Update Date | 08/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1050 25TH ST N
-----------------------------------------------------
City | SAINT PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33713-6842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-363-1622
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 10805
-----------------------------------------------------
City | SAINT PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33733-0805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-222-1963
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149011942
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CSW-687
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW13986
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------