Basic Information
| Provider Information | |||||||||
| NPI: | 1093289530 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | CARISSA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | BA, CT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020 WOODMAN DR STE 330 | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454321410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372530606 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1020 WOODMAN DR STE 330 | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454321410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372530606 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2019 | ||||||||
| LastUpdateDate: | 11/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | C.2002974 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.