Provider Demographics
NPI:1396895900
Name:MIZUMOTO, MAVIS A (PHD)
Entity type:Individual
Prefix:
First Name:MAVIS
Middle Name:A
Last Name:MIZUMOTO
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 1:2603 PETER ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-2013
Mailing Address - Country:US
Mailing Address - Phone:808-735-2378
Mailing Address - Fax:
Practice Address - Street 1:1268 YOUNG ST
Practice Address - Street 2:STE 200
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-1801
Practice Address - Country:US
Practice Address - Phone:808-735-2378
Practice Address - Fax:808-597-8183
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY-481103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI040501-01Medicaid
HIPSY481-01OtherMDX
HIPSY481-01OtherDESERT MUTUAL
HI192907OtherHMN
HIPSY481-01OtherCIGNA
HI192907OtherHMA
HIC044590-8OtherHMSA
HI0007919184OtherAETNA
HI192907OtherSUMMERLIN
HIPSY481-01OtherUHC
HI192907OtherHMN