Provider Demographics
NPI:1043963762
Name:MIRZA, MUSSERAT
Entity type:Individual
Prefix:
First Name:MUSSERAT
Middle Name:
Last Name:MIRZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4567 S FOXWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53228-4403
Mailing Address - Country:US
Mailing Address - Phone:551-998-1587
Mailing Address - Fax:
Practice Address - Street 1:1020 N 12TH ST STE 200
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-1308
Practice Address - Country:US
Practice Address - Phone:414-773-4312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI807-228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist