Basic Information
| Provider Information | |||||||||
| NPI: | 1568690725 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIZER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | LEAH | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 32709 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379302709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655586484 | ||||||||
| FaxNumber: | 8655844037 | ||||||||
| Practice Location | |||||||||
| Address1: | 8904 CROSS PARK DR | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379234703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656902671 | ||||||||
| FaxNumber: | 8656906445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2009 | ||||||||
| LastUpdateDate: | 06/24/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 8338 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
| ID | Type | State | Issuer | Description | CH4394 | 01 | TN | MEDICARE RAILROAD-GROUP | OTHER | 1514521 | 05 | TN | MEDICAID | 4232090 | 01 | TN | BLUE CROSS BLUE SHIELD OF TN | OTHER |