Healthcare Provider Details

I. General information

NPI: 1598276925
Provider Name (Legal Business Name): AMBER RENEE MIZE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2017
Last Update Date: 03/31/2023
Certification Date: 03/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 INDEPENDENCE DR STE E
WARNER ROBINS GA
31088-7811
US

IV. Provider business mailing address

107 INDEPENDENCE DR STE E
WARNER ROBINS GA
31088-7811
US

V. Phone/Fax

Practice location:
  • Phone: 478-217-2259
  • Fax: 229-217-2295
Mailing address:
  • Phone: 478-217-2259
  • Fax: 478-217-2295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW006101
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: