Healthcare Provider Details

I. General information

NPI: 1154497220
Provider Name (Legal Business Name): WILLIAM ASHLEY MIZELLE JR. LCAS,LCMHC,CCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2602 COURTIER DR
GREENVILLE NC
27834-7818
US

IV. Provider business mailing address

1492 TULL RD
GREENVILLE NC
27858-8366
US

V. Phone/Fax

Practice location:
  • Phone: 252-752-0483
  • Fax: 252-757-3172
Mailing address:
  • Phone: 252-814-5441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6860
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number10014
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6860
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1061
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: