Healthcare Provider Details

I. General information

NPI: 1073941944
Provider Name (Legal Business Name): GREGORY MIZELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2013
Last Update Date: 12/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 DOUGLAS AVE SUITE 2155-4
ALTAMONTE SPRINGS FL
32714-2569
US

IV. Provider business mailing address

455 DOUGLAS AVE SUITE 2155-4
ALTAMONTE SPRINGS FL
32714-2569
US

V. Phone/Fax

Practice location:
  • Phone: 407-529-4940
  • Fax: 321-952-0294
Mailing address:
  • Phone: 407-529-4940
  • Fax: 321-952-0294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: