Healthcare Provider Details

I. General information

NPI: 1538440557
Provider Name (Legal Business Name): TERRY MIZELL LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2011
Last Update Date: 09/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9025 TYNE TRL
FORT WORTH TX
76118-7502
US

IV. Provider business mailing address

9025 TYNE TRL
FORT WORTH TX
76118-7502
US

V. Phone/Fax

Practice location:
  • Phone: 817-595-4063
  • Fax:
Mailing address:
  • Phone: 817-595-4063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number19962
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: