Provider Demographics
NPI:1639471832
Name:MIZUNO, MARIE
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:MIZUNO
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 1:1233 S LA CIENEGA BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-2520
Mailing Address - Country:US
Mailing Address - Phone:310-855-0031
Mailing Address - Fax:310-855-0138
Practice Address - Street 1:1233 S LA CIENEGA BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-2520
Practice Address - Country:US
Practice Address - Phone:310-855-0031
Practice Address - Fax:310-855-0138
Is Sole Proprietor?:No
Enumeration Date:2010-11-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW703871041C0700X
CAASW33330104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker