Healthcare Provider Details

I. General information

NPI: 1851796221
Provider Name (Legal Business Name): KIMBERLY MIZERIK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2014
Last Update Date: 10/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 S 12TH ST
WACO TX
76701-1810
US

IV. Provider business mailing address

PO BOX 890
WACO TX
76703-0890
US

V. Phone/Fax

Practice location:
  • Phone: 254-752-3451
  • Fax: 254-756-3133
Mailing address:
  • Phone: 254-752-3451
  • Fax: 254-756-3133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number70015
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: