Healthcare Provider Details

I. General information

NPI: 1861054082
Provider Name (Legal Business Name): ATHINA MIZERO LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2019
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13640 STATE ROUTE 22
CANAAN NY
12029-3506
US

IV. Provider business mailing address

123 RYCKMAN AVE APT 3R
ALBANY NY
12208-2281
US

V. Phone/Fax

Practice location:
  • Phone: 518-781-4567
  • Fax:
Mailing address:
  • Phone: 631-944-0817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number099901
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number099901
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: