Basic Information
| Provider Information | |||||||||
| NPI: | 1477828556 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIZOGUCHI | ||||||||
| FirstName: | BRIAN | ||||||||
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| Credential: | CDP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 203 N WASHINGTON ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992010233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094448888 | ||||||||
| FaxNumber: | 5094447806 | ||||||||
| Practice Location | |||||||||
| Address1: | 5921 N MARKET ST | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992082484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094871604 | ||||||||
| FaxNumber: | 5094826286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2012 | ||||||||
| LastUpdateDate: | 03/21/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CP60145164 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.