Healthcare Provider Details

I. General information

NPI: 1215973466
Provider Name (Legal Business Name): MICHAEL L MIZE LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 S 70TH ST
FORT SMITH AR
72903-5017
US

IV. Provider business mailing address

3111 S 70TH ST
FORT SMITH AR
72903-5017
US

V. Phone/Fax

Practice location:
  • Phone: 479-452-6650
  • Fax: 479-452-5847
Mailing address:
  • Phone: 479-452-6650
  • Fax: 479-452-5847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP0605028
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: