Healthcare Provider Details

I. General information

NPI: 1609113844
Provider Name (Legal Business Name): JULIE ANN MIZAK LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8114 SANDPIPER CIR STE 215
NOTTINGHAM MD
21236-5902
US

IV. Provider business mailing address

626 REVOLUTION ST
HAVRE DE GRACE MD
21078-3320
US

V. Phone/Fax

Practice location:
  • Phone: 410-933-9000
  • Fax: 410-933-0125
Mailing address:
  • Phone: 410-939-8744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number16750
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1225005580
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: