Healthcare Provider Details

I. General information

NPI: 1609308550
Provider Name (Legal Business Name): DEBORAH J MIZELL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2017
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 5TH ST
SANTA ROSA CA
95404-4307
US

IV. Provider business mailing address

1008 5TH ST
SANTA ROSA CA
95404-4307
US

V. Phone/Fax

Practice location:
  • Phone: 707-242-1910
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number70830
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number86812
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: