Provider Demographics
NPI:1336660307
Name:MIZELL, HALEY
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:MIZELL
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 1:2440 VASSAR ST STE 3
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-3224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2523 EL PORTAL DR
Practice Address - Street 2:
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-3305
Practice Address - Country:US
Practice Address - Phone:510-439-3130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-29
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 172V00000X
CA390200000X
AMFT144097106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program