Healthcare Provider Details

I. General information

NPI: 1457929341
Provider Name (Legal Business Name): CALEB ZACHARIAH MIZE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2021
Last Update Date: 06/16/2021
Certification Date: 06/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 BRIGGS ST STE 990
SAN ANTONIO TX
78224-1287
US

IV. Provider business mailing address

305 NE LOOP 820 STE 200
HURST TX
76053-7211
US

V. Phone/Fax

Practice location:
  • Phone: 210-226-9536
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number118254
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: