Basic Information
| Provider Information | |||||||||
| NPI: | 1083658173 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4530 GLENNWOOD DR | ||||||||
| Address2: | |||||||||
| City: | EVANS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 308093222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067330188 | ||||||||
| FaxNumber: | 7067317190 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 FREEDOM WAY | ||||||||
| Address2: | 26 | ||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309046258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067330188 | ||||||||
| FaxNumber: | 7067317190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 3271 | GA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.