Provider Demographics
NPI:1467077032
Name:MIZELL, KERRY LEON (LPC)
Entity Type:Individual
Prefix:MR
First Name:KERRY
Middle Name:LEON
Last Name:MIZELL
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23607-5530
Mailing Address - Country:US
Mailing Address - Phone:757-715-4566
Mailing Address - Fax:
Practice Address - Street 1:200 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23607-5530
Practice Address - Country:US
Practice Address - Phone:757-715-4566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701008557101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional