Provider Demographics
NPI:1821870577
Name:YAMAMOTO, MIZUHO
Entity Type:Individual
Prefix:
First Name:MIZUHO
Middle Name:
Last Name:YAMAMOTO
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 1:2446 UNIVERSITY AVE W STE 104
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1945
Mailing Address - Country:US
Mailing Address - Phone:651-890-2690
Mailing Address - Fax:612-524-5527
Practice Address - Street 1:2446 UNIVERSITY AVE W STE 104
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1945
Practice Address - Country:US
Practice Address - Phone:612-235-6743
Practice Address - Fax:612-524-5527
Is Sole Proprietor?:No
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN311091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical