Healthcare Provider Details

I. General information

NPI: 1013749399
Provider Name (Legal Business Name): MIZANI THERAPEUTIC SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2024
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 CHATHAM RD # 5051
SPRINGFIELD IL
62704-4188
US

IV. Provider business mailing address

2501 CHATHAM RD # 5051
SPRINGFIELD IL
62704-4188
US

V. Phone/Fax

Practice location:
  • Phone: 773-916-6513
  • Fax:
Mailing address:
  • Phone: 773-916-6513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: CHLOE S. GLISPIE- GOGINS
Title or Position: CEO
Credential:
Phone: 773-916-6513