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NPI Code Detail

MEDICARE: BRADLEY S MAZICK PHD,HSPP

MEDICARE: BRADLEY S MAZICK PHD,HSPP
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
1103TC0700XClinical Psychologist20041080IN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1518933779
Entity Type Code : Individual
Provider Name (Legal Business Name) : BRADLEY S MAZICK PHD,HSPP
Provider Business Mailing Address
First Line : 1920 RIDGEDALE RD
Second Line :
City : SOUTH BEND
State : IN
Zip : 46614-2243
Country : US
Telephone Number : 574-231-8000
Fax Number : 574-231-8013
Provider Business Practice Location Address
First Line : 1920 RIDGEDALE RD
Second Line :
City : SOUTH BEND
State : IN
Zip : 46614-2243
Country : US
Telephone Number : 574-231-8000
Fax Number : 574-231-8013
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/27/2006
Last Update Date : 07/22/2014

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