Healthcare Provider Details

I. General information

NPI: 1639471832
Provider Name (Legal Business Name): MARIE MIZUNO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2010
Last Update Date: 09/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 S LA CIENEGA BLVD
LOS ANGELES CA
90035-2520
US

IV. Provider business mailing address

1233 S LA CIENEGA BLVD
LOS ANGELES CA
90035-2520
US

V. Phone/Fax

Practice location:
  • Phone: 310-855-0031
  • Fax: 310-855-0138
Mailing address:
  • Phone: 310-855-0031
  • Fax: 310-855-0138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW70387
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW33330
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: