Healthcare Provider Details

I. General information

NPI: 1285903559
Provider Name (Legal Business Name): TYANA LASHUN MIZELL BSW, MSCJ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2011
Last Update Date: 12/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

982 FOREST PATH
STONE MTN GA
30088-2609
US

IV. Provider business mailing address

982 FOREST PATH
STONE MTN GA
30088-2609
US

V. Phone/Fax

Practice location:
  • Phone: 770-875-0721
  • Fax: 770-676-5860
Mailing address:
  • Phone: 770-875-0721
  • Fax: 770-676-5860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: