Healthcare Provider Details

I. General information

NPI: 1780348649
Provider Name (Legal Business Name): SAMANTHA MIZE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2021
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2381 SUNRISE HWY
ISLIP NY
11751-2030
US

IV. Provider business mailing address

11 WOODBINE AVE
WEST BABYLON NY
11704-7814
US

V. Phone/Fax

Practice location:
  • Phone: 631-319-0165
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number012637
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: