Healthcare Provider Details

I. General information

NPI: 1770029472
Provider Name (Legal Business Name): ELIZABETH MOORE MIZE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2017
Last Update Date: 02/20/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 S WASHITA AVE
WYNNEWOOD OK
73098-7820
US

IV. Provider business mailing address

1580 COUNTY ROAD 33900
POWDERLY TX
75473-5002
US

V. Phone/Fax

Practice location:
  • Phone: 405-665-4385
  • Fax: 405-665-6396
Mailing address:
  • Phone: 918-443-7063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11224
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: