Provider Demographics
NPI:1861054082
Name:MIZERO, ATHINA (LMSW)
Entity type:Individual
Prefix:
First Name:ATHINA
Middle Name:
Last Name:MIZERO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 RYCKMAN AVE APT 3R
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-2281
Mailing Address - Country:US
Mailing Address - Phone:631-944-0817
Mailing Address - Fax:
Practice Address - Street 1:13640 STATE ROUTE 22
Practice Address - Street 2:
Practice Address - City:CANAAN
Practice Address - State:NY
Practice Address - Zip Code:12029-3506
Practice Address - Country:US
Practice Address - Phone:518-781-4567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY099901101Y00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY099901OtherLISCENSE NUMBER