Healthcare Provider Details

I. General information

NPI: 1750270294
Provider Name (Legal Business Name): BENJAMIN LARKIN MIZE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BENJAMIN LARKIN MIZE PATTERSON

II. Dates (important events)

Enumeration Date: 06/30/2025
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 WIND HAVEN DR STE 202
NICHOLASVILLE KY
40356-8036
US

IV. Provider business mailing address

549 MADISON POINT DR
LEXINGTON KY
40515-4824
US

V. Phone/Fax

Practice location:
  • Phone: 859-230-8121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number299583
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: