=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720051386
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES SCOTT MIZES PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2006
-----------------------------------------------------
Last Update Date | 06/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 235 HIGH ST SUITE 608
-----------------------------------------------------
City | MORGANTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26505-5429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-413-4728
-----------------------------------------------------
Fax | 304-581-3201
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 44 MCKINLEY ST
-----------------------------------------------------
City | MORGANTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26501-4265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-685-6062
-----------------------------------------------------
Fax | 304-581-3201
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 763
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------