Provider Demographics
NPI:1598208977
Name:MIZELL, EARLINE
Entity Type:Individual
Prefix:
First Name:EARLINE
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:PO BOX 940924
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32794-0924
Mailing Address - Country:US
Mailing Address - Phone:407-682-3900
Mailing Address - Fax:321-952-0294
Practice Address - Street 1:455 DOUGLAS AVE
Practice Address - Street 2:SUITE 2155-4
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-2569
Practice Address - Country:US
Practice Address - Phone:407-682-3900
Practice Address - Fax:321-952-0294
Is Sole Proprietor?:No
Enumeration Date:2016-12-02
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000000000Medicaid