Provider Demographics
NPI:1538949508
Name:CANDACE MIZAUR LLC
Entity type:Organization
Organization Name:CANDACE MIZAUR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:
Authorized Official - Last Name:MIZAUR
Authorized Official - Suffix:
Authorized Official - Credentials:PLMHP
Authorized Official - Phone:402-807-0228
Mailing Address - Street 1:9819 S 168TH AVE STE 6F
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68136-1154
Mailing Address - Country:US
Mailing Address - Phone:402-807-0228
Mailing Address - Fax:
Practice Address - Street 1:9819 S 168TH AVE STE 6F
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68136-1154
Practice Address - Country:US
Practice Address - Phone:402-807-0228
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty