Healthcare Provider Details

I. General information

NPI: 1487863783
Provider Name (Legal Business Name): HOLLY GELFOND MIZUTANI EDD, PMHCNS-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 08/11/2020
Certification Date: 08/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 DISTRICT AVE
BURLINGTON MA
01803-5069
US

IV. Provider business mailing address

150 RIVERSIDE AVE
MEDFORD MA
02155-4726
US

V. Phone/Fax

Practice location:
  • Phone: 781-910-4056
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number266902
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: