Provider Demographics
NPI:1891110425
Name:IWAMOTO, MIZUE (MS, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:MIZUE
Middle Name:
Last Name:IWAMOTO
Suffix:
Gender:F
Credentials:MS, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 8TH ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-3522
Mailing Address - Country:US
Mailing Address - Phone:518-276-2884
Mailing Address - Fax:
Practice Address - Street 1:110 8TH ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-3522
Practice Address - Country:US
Practice Address - Phone:518-276-2884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-18
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0020952255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer