Provider Demographics
NPI:1588282644
Name:MITZEL, LYDIA JONAE
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:JONAE
Last Name:MITZEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 MILLBRANCH RD
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1672
Mailing Address - Country:US
Mailing Address - Phone:601-255-5264
Mailing Address - Fax:855-625-0559
Practice Address - Street 1:32 MILLBRANCH RD
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1672
Practice Address - Country:US
Practice Address - Phone:601-255-5264
Practice Address - Fax:855-625-0559
Is Sole Proprietor?:No
Enumeration Date:2020-07-06
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician