Healthcare Provider Details

I. General information

NPI: 1275240020
Provider Name (Legal Business Name): MS. LORI MIZWICKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2022
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3232 KERLIKOWSKE RD
COLOMA MI
49038-8969
US

IV. Provider business mailing address

3232 KERLIKOWSKE RD
COLOMA MI
49038-8969
US

V. Phone/Fax

Practice location:
  • Phone: 269-208-3653
  • Fax:
Mailing address:
  • Phone: 269-208-3653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5202003449
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: