Provider Demographics
NPI:1306316724
Name:MIZELL, TANYA D (NCC LPC CCTP ASDI)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:D
Last Name:MIZELL
Suffix:
Gender:F
Credentials:NCC LPC CCTP ASDI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3763 17TH ST
Mailing Address - Street 2:
Mailing Address - City:ECORSE
Mailing Address - State:MI
Mailing Address - Zip Code:48229-1339
Mailing Address - Country:US
Mailing Address - Phone:734-237-7199
Mailing Address - Fax:
Practice Address - Street 1:3763 17TH ST
Practice Address - Street 2:
Practice Address - City:ECORSE
Practice Address - State:MI
Practice Address - Zip Code:48229-1339
Practice Address - Country:US
Practice Address - Phone:734-237-7199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-28
Last Update Date:2024-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401224388101YM0800X, 101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
1732823OtherNATIONAL BOARD FOR CERTIFIED COUNSELORS (NBCC)
7A7B6OtherCAGE/NCAGE
KLDNLGNS98C3OtherSAM UNIQUE ENTITY ID
14898250OtherCAQH PROVIEW