Healthcare Provider Details

I. General information

NPI: 1306316724
Provider Name (Legal Business Name): TANYA D MIZELL NCC LPC CCTP ASDI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2018
Last Update Date: 06/29/2024
Certification Date: 06/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3763 17TH ST
ECORSE MI
48229-1339
US

IV. Provider business mailing address

3763 17TH ST
ECORSE MI
48229-1339
US

V. Phone/Fax

Practice location:
  • Phone: 734-237-7199
  • Fax:
Mailing address:
  • Phone: 734-237-7199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401224388
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401224388
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401224388
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: