Provider Demographics
NPI:1932122058
Name:WOOD-VON MIZENER, MITZI L (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MITZI
Middle Name:L
Last Name:WOOD-VON MIZENER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3907 BONNAVISTA DR
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37076-1122
Mailing Address - Country:US
Mailing Address - Phone:615-673-6737
Mailing Address - Fax:615-296-4567
Practice Address - Street 1:395 INTERSTATE DR
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-3108
Practice Address - Country:US
Practice Address - Phone:615-673-6737
Practice Address - Fax:615-296-4567
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2192103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3689125Medicaid
TN3689127Medicaid
TN3689125Medicaid
TN3689127Medicare ID - Type UnspecifiedWSI - RESASSIGNED
TNS75841Medicare UPIN