Healthcare Provider Details

I. General information

NPI: 1508104761
Provider Name (Legal Business Name): CHARLES JOHN MEZEY LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2013
Last Update Date: 01/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 E INDIAN SCHOOL RD
PHOENIX AZ
85012-1839
US

IV. Provider business mailing address

650 E INDIAN SCHOOL RD
PHOENIX AZ
85012-1839
US

V. Phone/Fax

Practice location:
  • Phone: 602-361-9019
  • Fax:
Mailing address:
  • Phone: 602-361-9019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLMSW11878
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: