Basic Information
Provider Information | |||||||||
NPI: | 1407835291 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MAZIN | ||||||||
FirstName: | MAKENZIE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DSCPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1501 DUKE ST | ||||||||
Address2: | SUITE 150 | ||||||||
City: | ALEXANDRIA | ||||||||
State: | VA | ||||||||
PostalCode: | 223143468 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7035355491 | ||||||||
FaxNumber: | 7035355494 | ||||||||
Practice Location | |||||||||
Address1: | 1725 DUKE ST | ||||||||
Address2: | GROUND 04 | ||||||||
City: | ALEXANDRIA | ||||||||
State: | VA | ||||||||
PostalCode: | 223143456 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7032993111 | ||||||||
FaxNumber: | 7032991556 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/11/2006 | ||||||||
LastUpdateDate: | 11/28/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305203359 | VA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | F8710015 | 01 | DC | CAREFIRST BLUE CROSS BLUE SHIELD | OTHER |