Provider Demographics
NPI:1013117902
Name:MIZELLE-JOHNSON, NATHALIE DIONA (PHD)
Entity Type:Individual
Prefix:DR
First Name:NATHALIE
Middle Name:DIONA
Last Name:MIZELLE-JOHNSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2028B CAMBRIA DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-0089
Mailing Address - Country:US
Mailing Address - Phone:650-296-7599
Mailing Address - Fax:
Practice Address - Street 1:1709 EVANS ST
Practice Address - Street 2:SUITE B
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-5772
Practice Address - Country:US
Practice Address - Phone:252-756-7848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-19
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701006205101YP2500X
NC2084101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103993Medicaid