Healthcare Provider Details

I. General information

NPI: 1477828556
Provider Name (Legal Business Name): BRIAN MIZOGUCHI CDP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2012
Last Update Date: 03/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5921 N MARKET ST
SPOKANE WA
99208-2484
US

IV. Provider business mailing address

203 N WASHINGTON ST STE 300
SPOKANE WA
99201-0233
US

V. Phone/Fax

Practice location:
  • Phone: 509-487-1604
  • Fax: 509-482-6286
Mailing address:
  • Phone: 509-444-8888
  • Fax: 509-444-7806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP60145164
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: