Provider Demographics
NPI:1821158973
Name:MIZE, REBECCA (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:
Last Name:MIZE
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:MRS
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:GOVERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTRL
Mailing Address - Street 1:2015 VAUGHN RD NW
Mailing Address - Street 2:SUITE 130
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-7801
Mailing Address - Country:US
Mailing Address - Phone:770-425-6661
Mailing Address - Fax:770-425-1189
Practice Address - Street 1:2015 VAUGHN RD NW
Practice Address - Street 2:SUITE 130
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-7801
Practice Address - Country:US
Practice Address - Phone:770-425-6661
Practice Address - Fax:770-425-1189
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002491225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics