MEDICARE: THE MIZE COLLECTIVE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1396535167
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE MIZE COLLECTIVE

Provider Business Mailing Address
First Line	:	1314 ECOLA VALLEY CT
Second Line	:
City	:	WAKE FOREST
State	:	NC
Zip	:	27587-4915
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1314 ECOLA VALLEY CT
Second Line	:
City	:	WAKE FOREST
State	:	NC
Zip	:	27587-4915
Country	:	US
Telephone Number	:	984-212-2757
Fax Number	:

Authorized Official
Title or Position	:	OWNER/EMPLOYEE
Name	:	AUTUMN MIZE
Credential	:	LCMHC-A
Telephone Number	:	984-212-2757

Provider Enumeration Date	:	05/07/2025
Last Update Date	:	05/07/2025

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Directions to “THE MIZE COLLECTIVE ” Practice Location

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