MEDICARE: AUTUMN KAYLEN MIZE LCMHC-A

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
1	101YM0800X	Mental Health Counselor	A19989	NC

General Provider Information

NPI Number	:	1881430023
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUTUMN KAYLEN MIZE LCMHC-A

Provider Business Mailing Address
First Line	:	1314 ECOLA VALLEY CT
Second Line	:
City	:	WAKE FOREST
State	:	NC
Zip	:	27587-4915
Country	:	US
Telephone Number	:	984-212-2757
Fax Number	:

Provider Business Practice Location Address
First Line	:	1314 ECOLA VALLEY CT
Second Line	:
City	:	WAKE FOREST
State	:	NC
Zip	:	27587-4915
Country	:	US
Telephone Number	:	984-212-2757
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2024
Last Update Date	:	07/08/2024

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