Provider Information for 1306316724
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TANYA D MIZELL NCC LPC CCTP ASDI
Sex: Female
NPI: 1306316724
Last Updated: 2024-06-29
Certification Date: 2024-06-29
Certification Date: 2024-06-29
Details
| Name | Value | ||||||||||||||||||||
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| NPI | 1306316724 | ||||||||||||||||||||
| Enumeration Date | 2018-11-28 | ||||||||||||||||||||
| NPI Type | NPI-1 Individual | ||||||||||||||||||||
| Sole Proprietor | YES | ||||||||||||||||||||
| Status | Active | ||||||||||||||||||||
| Mailing Address | 3763 17TH ST ECORSE, MI 48229-1339 United States Phone: 734-237-7199 | Fax: | ||||||||||||||||||||
| Primary Practice Address | 3763 17TH ST ECORSE, MI 48229-1339 United States Phone: 734-237-7199 | Fax: | ||||||||||||||||||||
| Secondary Practice Address(es) | 3763 17TH ST | ||||||||||||||||||||
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