Healthcare Provider Details

I. General information

NPI: 1780955831
Provider Name (Legal Business Name): MIZUHO KANAZAWA LPC, LCAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2012
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 JOHN ST STE 314
FORT LEE NJ
07024-2586
US

IV. Provider business mailing address

1605 JOHN ST STE 314
FORT LEE NJ
07024-2586
US

V. Phone/Fax

Practice location:
  • Phone: 201-298-3131
  • Fax:
Mailing address:
  • Phone: 201-298-3131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC00746100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code101200000X
TaxonomyDrama Therapist
License Number000266-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: