MEDICARE: DR. STACEY MIZOKAWA PH.D.

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	103TC0700X	Clinical Psychologist	PSY17458	CA

General Provider Information

NPI Number	:	1477680361
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STACEY MIZOKAWA PH.D.

Provider Business Mailing Address
First Line	:	2566 OVERLAND AVE
Second Line	:	SUITE 500A
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-5600
Country	:	US
Telephone Number	:	310-801-1407
Fax Number	:	310-202-1471

Provider Business Practice Location Address
First Line	:	2566 OVERLAND AVE
Second Line	:	SUITE 500A
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-5600
Country	:	US
Telephone Number	:	310-801-1407
Fax Number	:	310-202-1471

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	05/21/2021

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