Provider Demographics
NPI:1609113844
Name:MIZAK, JULIE ANN (LCSW-C)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:ANN
Last Name:MIZAK
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 REVOLUTION ST
Mailing Address - Street 2:
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078-3320
Mailing Address - Country:US
Mailing Address - Phone:410-939-8744
Mailing Address - Fax:
Practice Address - Street 1:8114 SANDPIPER CIR STE 215
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-5902
Practice Address - Country:US
Practice Address - Phone:410-933-9000
Practice Address - Fax:410-933-0125
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16750104100000X
MD1225005580101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty