Healthcare Provider Details

I. General information

NPI: 1962277103
Provider Name (Legal Business Name): TINA L MIZLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2023
Last Update Date: 07/26/2024
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 STODDARD RD
RICHMOND MI
48062-2505
US

IV. Provider business mailing address

51173 CENTRAL VILLAGE RD APT 304
CHESTERFIELD MI
48047-3575
US

V. Phone/Fax

Practice location:
  • Phone: 810-392-2167
  • Fax:
Mailing address:
  • Phone: 586-961-3167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: