MEDICARE: ANGELA ROSE MAZUR MA,LLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	6301007928	MI

General Provider Information

NPI Number	:	1336302892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA ROSE MAZUR MA,LLP

Provider Business Mailing Address
First Line	:	2011 CROOKS RD
Second Line	:
City	:	ROYAL OAK
State	:	MI
Zip	:	48073-4049
Country	:	US
Telephone Number	:	248-414-4050
Fax Number	:	248-414-4053

Provider Business Practice Location Address
First Line	:	39343 LEDGATE DR
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48310-2339
Country	:	US
Telephone Number	:	586-939-2393
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/04/2008
Last Update Date	:	07/04/2008

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