1548338056 NPI number — LAUGHING MOON CENTER

Table of content: DR. MARY CHASE MIZE PHD, LPC (NPI 1073377834)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548338056 NPI number — LAUGHING MOON CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAUGHING MOON CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548338056
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4251 N SANDERS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85743-7716
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-682-7886
Provider Business Mailing Address Fax Number:
520-616-7140

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4251 N SANDERS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85743-7716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-682-7886
Provider Business Practice Location Address Fax Number:
520-616-7140
Provider Enumeration Date:
12/01/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
KIRAH
Authorized Official Middle Name:
CAROLYN
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
520-682-7886

Provider Taxonomy Codes

  • Taxonomy code: 302F00000X , with the licence number:  BH2126 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)