Provider Demographics
NPI:1922548759
Name:MIZUKAMI, TINA (MFT)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:MIZUKAMI
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2041 PIONEER CT STE 203
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-1729
Mailing Address - Country:US
Mailing Address - Phone:415-820-9696
Mailing Address - Fax:
Practice Address - Street 1:2041 PIONEER CT STE 203
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-1729
Practice Address - Country:US
Practice Address - Phone:415-820-9696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-27
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86242106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist