1760545834 NPI number — MS. SHIRLEY MAZOUREK MSW, LCSW-R

Table of content: MS. SHIRLEY MAZOUREK MSW, LCSW-R (NPI 1760545834)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760545834 NPI number — MS. SHIRLEY MAZOUREK MSW, LCSW-R

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAZOUREK
Provider First Name:
SHIRLEY
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSW, LCSW-R
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760545834
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1010 MAIN STREET
Provider Second Line Business Mailing Address:
ECMC OUTPATIENT CLINIC
Provider Business Mailing Address City Name:
BUFFALO
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-898-1675
Provider Business Mailing Address Fax Number:
716-898-1311

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 MAIN STREET
Provider Second Line Business Practice Location Address:
ECMC OUTPATIENT CLINIC
Provider Business Practice Location Address City Name:
BUFFALO
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-898-1675
Provider Business Practice Location Address Fax Number:
716-898-1311
Provider Enumeration Date:
12/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 074963 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0073074963 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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