=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710549134
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL HARVEY MAZALIC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2019
-----------------------------------------------------
Last Update Date | 07/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8599 KNOX SCHOOL RD
-----------------------------------------------------
City | MINERVA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44657-9437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-323-9649
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8599 KNOX SCHOOL RD
-----------------------------------------------------
City | MINERVA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44657-9437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-323-9649
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3747P1801X
-----------------------------------------------------
Taxonomy Name | Personal Care Attendant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------