Healthcare Provider Details

I. General information

NPI: 1497369607
Provider Name (Legal Business Name): SHELLY MIZE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2020
Last Update Date: 09/04/2020
Certification Date: 09/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 7TH ST
PARKERSBURG WV
26101-3803
US

IV. Provider business mailing address

2121 7TH ST
PARKERSBURG WV
26101-3803
US

V. Phone/Fax

Practice location:
  • Phone: 304-485-1721
  • Fax: 304-424-9424
Mailing address:
  • Phone: 304-485-1721
  • Fax: 304-424-9424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: