Healthcare Provider Details

I. General information

NPI: 1780164491
Provider Name (Legal Business Name): CHRISTINE Y MIZE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2018
Last Update Date: 08/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 SE BLUE PKWY
LEES SUMMIT MO
64063-4352
US

IV. Provider business mailing address

400 SE BLUE PKWY
LEES SUMMIT MO
64063-4352
US

V. Phone/Fax

Practice location:
  • Phone: 816-986-2169
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2018002424
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: