MEDICARE: ROBERTA (ROBIN) RAE MIZE LCMFT

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	106H00000X	Marriage & Family Therapist	LCM215	MD

General Provider Information

NPI Number	:	1710139225
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERTA (ROBIN) RAE MIZE LCMFT

Provider Business Mailing Address
First Line	:	7034 CARROL AVE.
Second Line	:
City	:	TAKOMA PARK
State	:	MD
Zip	:	20912
Country	:	US
Telephone Number	:	301-270-0078
Fax Number	:

Provider Business Practice Location Address
First Line	:	7034 CARROL AVE.
Second Line	:
City	:	TAKOMA PARK
State	:	MD
Zip	:	20912
Country	:	US
Telephone Number	:	301-270-0078
Fax Number	:

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

Provider Enumeration Date	:	10/15/2008
Last Update Date	:	10/15/2008

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