Basic Information
| Provider Information | |||||||||
| NPI: | 1912422965 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAZAREK | ||||||||
| FirstName: | JUSTINA | ||||||||
| MiddleName: | RAE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5438 PHILLIPS RICE RD | ||||||||
| Address2: | |||||||||
| City: | CORTLAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444109675 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5438 PHILLIPS RICE RD | ||||||||
| Address2: | |||||||||
| City: | CORTLAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444109675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073623780 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2017 | ||||||||
| LastUpdateDate: | 04/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | OTA006067 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 224Z00000X | 006067 | OH | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 224Z00000X | 128OT | WY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 224Z00000X | WY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.