Provider Demographics
NPI:1124553797
Name:ANDREA MIZE LLC
Entity Type:Organization
Organization Name:ANDREA MIZE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MIZE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:503-957-5947
Mailing Address - Street 1:3 MONROE PKWY
Mailing Address - Street 2:STE P 242
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-1486
Mailing Address - Country:US
Mailing Address - Phone:503-957-5947
Mailing Address - Fax:
Practice Address - Street 1:10175 SW BARBUR BLVD STE 300BG
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-5909
Practice Address - Country:US
Practice Address - Phone:503-957-5947
Practice Address - Fax:503-206-0926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-20
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR73281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty