Provider Demographics
NPI:1629516349
Name:ROSE, MIMI MIZE
Entity Type:Individual
Prefix:MRS
First Name:MIMI
Middle Name:MIZE
Last Name:ROSE
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 1:8121 EAGLE CIR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73135-6077
Mailing Address - Country:US
Mailing Address - Phone:318-402-6799
Mailing Address - Fax:
Practice Address - Street 1:1500 S MIDWEST BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-4946
Practice Address - Country:US
Practice Address - Phone:318-402-6799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-01
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist