Provider Demographics
NPI:1568814762
Name:MIZESKI, BRIAN JOSEPH (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:JOSEPH
Last Name:MIZESKI
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1053 CEDARVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:HEPHZIBAH
Mailing Address - State:GA
Mailing Address - Zip Code:30815-7205
Mailing Address - Country:US
Mailing Address - Phone:201-247-4358
Mailing Address - Fax:
Practice Address - Street 1:1053 CEDARVIEW CIR
Practice Address - Street 2:
Practice Address - City:HEPHZIBAH
Practice Address - State:GA
Practice Address - Zip Code:30815-7205
Practice Address - Country:US
Practice Address - Phone:201-247-4358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0026422255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer