Healthcare Provider Details

I. General information

NPI: 1013117902
Provider Name (Legal Business Name): NATHALIE DIONA MIZELLE-JOHNSON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 04/02/2021
Certification Date: 04/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1709 EVANS ST SUITE B
GREENVILLE NC
27834-5772
US

IV. Provider business mailing address

2028B CAMBRIA DR
GREENVILLE NC
27834-0089
US

V. Phone/Fax

Practice location:
  • Phone: 252-756-7848
  • Fax:
Mailing address:
  • Phone: 650-296-7599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701006205
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2084
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: