Healthcare Provider Details

I. General information

NPI: 1295187771
Provider Name (Legal Business Name): SANDRA A. MIZERAK LMHC,NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2016
Last Update Date: 07/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 FRENCH RD
NEW HARTFORD NY
13413-1054
US

IV. Provider business mailing address

429 OTSEGO ST
ILION NY
13357-2529
US

V. Phone/Fax

Practice location:
  • Phone: 315-404-1634
  • Fax:
Mailing address:
  • Phone: 315-404-1634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number000224-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: