Provider Demographics
NPI:1013749399
Name:MIZANI THERAPEUTIC SERVICES, LLC
Entity type:Organization
Organization Name:MIZANI THERAPEUTIC SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHLOE
Authorized Official - Middle Name:S
Authorized Official - Last Name:GLISPIE- GOGINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-916-6513
Mailing Address - Street 1:2501 CHATHAM RD # 5051
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-4188
Mailing Address - Country:US
Mailing Address - Phone:773-916-6513
Mailing Address - Fax:
Practice Address - Street 1:2501 CHATHAM RD # 5051
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-4188
Practice Address - Country:US
Practice Address - Phone:773-916-6513
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-15
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty