Healthcare Provider Details

I. General information

NPI: 1689054819
Provider Name (Legal Business Name): BRUCE MARTY MIZENER B.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2015
Last Update Date: 06/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3491 GANDY BLVD N STE 201
PINELLAS PARK FL
33781-2654
US

IV. Provider business mailing address

4811 20TH ST N
SAINT PETERSBURG FL
33714-3310
US

V. Phone/Fax

Practice location:
  • Phone: 727-547-0607
  • Fax:
Mailing address:
  • Phone: 727-710-2934
  • Fax:

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: