Provider Demographics
NPI:1750924049
Name:MIZZELLE, LINDA RAYE (LCSW)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:RAYE
Last Name:MIZZELLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 ARBOR DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-9550
Mailing Address - Country:US
Mailing Address - Phone:252-717-3097
Mailing Address - Fax:
Practice Address - Street 1:121 ARBOR DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-9550
Practice Address - Country:US
Practice Address - Phone:252-717-3097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-20
Last Update Date:2019-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0125391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical