Healthcare Provider Details

I. General information

NPI: 1093209561
Provider Name (Legal Business Name): TRINA T. MIZER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2018
Last Update Date: 02/04/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 E BRADFORLD PKY
SPRINGFIELD MO
65804
US

IV. Provider business mailing address

1300 E BRADFORD PKWY
SPRINGFIELD MO
65804-4264
US

V. Phone/Fax

Practice location:
  • Phone: 417-761-5000
  • Fax:
Mailing address:
  • Phone: 417-761-5000
  • Fax: 417-761-5111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2019038979
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: