Healthcare Provider Details

I. General information

NPI: 1679250252
Provider Name (Legal Business Name): JACQUELINE MIZE LMHC, ATR-P
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACQUELINE BONDOWSKI

II. Dates (important events)

Enumeration Date: 07/05/2023
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1259 E STATE ROAD 205
COLUMBIA CITY IN
46725-9492
US

IV. Provider business mailing address

2621 E JEFFERSON ST
WARSAW IN
46580-3880
US

V. Phone/Fax

Practice location:
  • Phone: 260-248-8176
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39004570A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: