Healthcare Provider Details

I. General information

NPI: 1730629320
Provider Name (Legal Business Name): MIZELLE PSYCHIATRIC ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2017
Last Update Date: 03/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3737 GLENWOOD AVE SUITE 100
RALEIGH NC
27612-5515
US

IV. Provider business mailing address

3737 GLENWOOD AVE SUITE 100
RALEIGH NC
27612-5515
US

V. Phone/Fax

Practice location:
  • Phone: 919-561-7999
  • Fax: 919-400-4395
Mailing address:
  • Phone: 919-561-7999
  • Fax: 919-400-4395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2008-01971
License Number StateNC

VIII. Authorized Official

Name: DR. ERIC Q MIZELLE
Title or Position: OWNER
Credential: M.D.
Phone: 919-561-7999