Basic Information
| Provider Information | |||||||||
| NPI: | 1154497220 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIZELLE | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | ASHLEY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | LCAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2245 STANTONSBURG RD | ||||||||
| Address2: | SUITE P | ||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278342868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527520483 | ||||||||
| FaxNumber: | 2527522971 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 PALADIN DR | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278347826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2523535346 | ||||||||
| FaxNumber: | 2523217300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1061 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 143KY | 01 | NC | BCBS | OTHER | 6111889 | 05 | NC | MEDICAID | 191488 | 01 | NC | MEDCOST | OTHER |