Healthcare Provider Details

I. General information

NPI: 1073377834
Provider Name (Legal Business Name): MARY CHASE MIZE PHD, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2024
Last Update Date: 02/16/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 W PEACHTREE ST NW STE 2625
ATLANTA GA
30309-3499
US

IV. Provider business mailing address

1201 W PEACHTREE ST NW STE 2625
ATLANTA GA
30309-3499
US

V. Phone/Fax

Practice location:
  • Phone: 404-590-7566
  • Fax:
Mailing address:
  • Phone: 404-590-7566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC012870
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: