Provider Demographics
NPI:1295187771
Name:MIZERAK, SANDRA A (LMHC,NCC)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:A
Last Name:MIZERAK
Suffix:
Gender:F
Credentials:LMHC,NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 OTSEGO ST
Mailing Address - Street 2:
Mailing Address - City:ILION
Mailing Address - State:NY
Mailing Address - Zip Code:13357-2529
Mailing Address - Country:US
Mailing Address - Phone:315-404-1634
Mailing Address - Fax:
Practice Address - Street 1:610 FRENCH RD
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-1054
Practice Address - Country:US
Practice Address - Phone:315-404-1634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000224-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health