Provider Demographics
NPI:1306225834
Name:MISE, MAIRIM
Entity Type:Individual
Prefix:MS
First Name:MAIRIM
Middle Name:
Last Name:MISE
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 1:2880 W OAKLAND PARK BLVD STE 231
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33311-1397
Mailing Address - Country:US
Mailing Address - Phone:786-863-0175
Mailing Address - Fax:
Practice Address - Street 1:2880 W OAKLAND PARK BLVD STE 231
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33311-1397
Practice Address - Country:US
Practice Address - Phone:786-863-0175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-29
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 12996101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health