Provider Demographics
NPI:1871255489
Name:YASUOKA, MIZUKA
Entity Type:Individual
Prefix:
First Name:MIZUKA
Middle Name:
Last Name:YASUOKA
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 1:2577 MASON LN
Mailing Address - Street 2:
Mailing Address - City:HOLT
Mailing Address - State:MI
Mailing Address - Zip Code:48842-2137
Mailing Address - Country:US
Mailing Address - Phone:832-889-9887
Mailing Address - Fax:
Practice Address - Street 1:3181 SANDHILL RD
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:MI
Practice Address - Zip Code:48854-9425
Practice Address - Country:US
Practice Address - Phone:517-455-0258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-11
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401223460101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty