Provider Demographics
NPI:1073941944
Name:MIZELL, GREGORY
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:MIZELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 DOUGLAS AVE
Mailing Address - Street 2:SUITE 2155-4
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-2569
Mailing Address - Country:US
Mailing Address - Phone:407-529-4940
Mailing Address - Fax:321-952-0294
Practice Address - Street 1:455 DOUGLAS AVE
Practice Address - Street 2:SUITE 2155-4
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-2569
Practice Address - Country:US
Practice Address - Phone:407-529-4940
Practice Address - Fax:321-952-0294
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-31
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker